Nordquist, Horace NEW YORK STATE DEPARTMENT OF HEALTH
# or
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
h
Horace Male
IN Date of Death,,27115 Agg If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village A- y Street Address
O Manner of Death E Natural Cause 0 Accident El Homicide ElSuicide riUndetermined �Pending
f Circumstances Investigation
la Medical Certifier Name Title
MD
O J. Phillips
Address
DVAMC 113 Holland Avenue, Albany, New York 12208
Death Certificate Filed District lNumber Regis98 ter Number
City, Town or Village Albany
>< ❑Burial Date Cemetery or Cre atc�ry
['Entombment �'�� Pine - v0 C� �r
A ress n�� f ff __ cc
jR1Cremation 1 11_Y i�.YXL ' Gw_fi�tU(.(r .)1 t y i -O b
Date Place Removed
Z ri❑Removal and/or Held
and/or Address
.= Hold
V)
Date Point of
ti❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home OWL jL 14 t 11 EL
, Address It L fihriUc— Sl (4,W1[ lYcti .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Ir
lu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued c8/27/15 Registrar of Vital Statistics James Arrington
(signature)
District Number 198 Place
DVAMC 113 Holland Avenue, Albany, New York 12208
:;,.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� 0 arm
t� Date of Disposition 1 '1 t i�' Place of Disposition �� .,�.� try
2 (address)
i! (section) A. ,(lot number) S 4- (grave number)
Name of Sexton or Per on in Ch ge of Premises j1
lease print)
• Signature Title l' Ml �dl
9
(over)
DOH-1555 (02/2004)