Poellath, Margarethe NEW YORK STATE DEPARTMENT OF HEALTH i-I i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
• Margarethe Poellath Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/02/2015 79 War or Dates No
1 Place of Death Hospital, Institution
City ,Town or Village City of Albany or Street Address Albany Medical Center
oa Manner of Death ® Cause Natural ❑ Accident ❑ Undetermined ❑ Pending
❑ Homicide ❑ Suicide Circumstances Investigation
Medical Certifier Name Title
fa Christopher Keenan DO
Address
43 New Scotland Ave. Albany, NY 12208
o' Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1404
Date Cemetery or Crematory
❑ Burial 07/02/2015 Pine View Crematorium
❑ Entombment Address
® Cremation
Queensbury, NY
Date Place Removed
Z Removal and/or Held
❑ and/or Address
F' Hold
Cl)
Date Point of
a. Transportation Shipment
N ❑ By Common p Carrier Destination
,
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
yl° Name of Funeral Home
Barton-McDermott Funeral Home, Inc. 00141
Address
4 9 Pine St. Chestertown, NY 12817
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
0. Permission is hereby granted to dispose of the human remain above as indi ted. 9
Date 07/02/2015 Registrar of Vital Stati
Issued (signature)
4.
District Number 101 Place City of Albany, NY J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1I1 i)S Place of Disposition U,", (KJ-tlry
Lu (address)
ui
co
W. (section) (lot number) (grave number)
0
0 c
wl Name of Sexton or Person in Charge of Premises ►,, .)chart
(please print)
Signature ATitle
(over)
DOH-1555 (02/2004)