Powell, Edward k - f.
NEW YORK STATE DEPARTMENT OF HEALTH 7.50
Vital Records Section Burial - Transit Permit
`�,1�$;a Name First Middle Last Sex
Edward C. Powell Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 24, 2016 68 War or Dates
�' : Place of Death Hospital, Institution or
? City, Town or Village Glens Falls Street Address 23 Jay Street
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
1Eric Pillemer MD
} Address
"~...' 10 Park Street,Glens Falls, NY
;Y.. Death Certificate Filed District Number Register Number
,fir:; City, Town or Village Glens Falls, NY 5 b Q I 5
❑Burial Date Cemetery or Crematory
March 25, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
Hold
Cl)
0 Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rx Permit Issued to Registration Number
** Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
R:::' 53 Quaker Road, Queensbury,NY 12804
... . Name of Funeral Firm Making Disposition or to Whom
' ". Remains are Shipped, If Other than Above
Address
r Permission is hereby granted to dispose of the human remains described above as indicated.
1
$.::: �
;:; ,3 Date Issued /'?--q / 46 Registrar of Vital Statistics (A)f;AAi 1/lJ
y (signat e)
District Number 560( Place 6 Al(si,vs RA 5 ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3/Zi'IL Place of Disposition ,fit, �fwntl ('w.,.
(ad7ress)
W
N
(section) (lot number) C (grave number)
p Name of Sexton or Person in Charge of remises dr
�i� cr Jwn -
Z /1 (phase print)
W
Signature L• Title roivairi(l
(over)
DOH-1555(02/2004)