Perkrul, Michael NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section BUrial - Transit Permit
Name First Middle Last Sex
MICHAEL H. PERKRUL MALE
Date of Death Age If Veteran of U.S.Armed Forces,
01/16/2015 54 War or Dates NO
- Place of Death Hospital, Institution
W'" City,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
0 Manner of Death Natural ❑ Undetermined ❑ Pending
Ili ® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
° Medical Certifier Name Title
p VINIT PATIL MD
Address
43 NEW SCOTLAND AVE. ALBANY, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 139
Date Cemetery or Crematory
❑ Burial 01/21/2015 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
F' Hold
0 Date Point of
p' Transportation Shipment
U) ❑ By Common Destination
0 Carrier
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home WILCOX & REGAN FUNERAL HOME 01821
Address
11 ALGONKIN ST. TICONDEROGA, NY
Name of Funeral Firm Making Disposition or to Whom
1-7 Remains are Shipped, If Other than Above
2 Address
w
O Permission is hereby granted to dispose of the human remains described above as indicAed.
Date 01/20/2015 Registrar of Vital Statistic ` o
Issued (signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordancecc with thisth permit on:
zDate of Disposition 171I�J Place of Disposition 'bee Owa lr1�w4'0(1,..-
ur (address)
ur
Cl)
Cl (section) (lot number) (grave number)
0
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w A)-17,1_
Name of Sexton or Person in Charge of Premises �trvor
(please print)
Signature
6Signature , T- Title aethrr
(over)
DOH-1555 (02/2004)