Poulin, Duane NEW YORK STATE DEPARTMENT OF HEALTH -77
Vital Records Section Burial ran it Permit
.' Name First Middle Last Sex
DUANE A POULIN Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 25,2015 68 War or Dates 1968 1970
Place of Death ALBANY VAMC ALBANY NEW YORK Hospital, Institution or
• City, Town or Village Street Address 113 HOLLAND AVE,ALBANY NEW YORK 12208
Manner of Death m Natural Cause ❑Accident Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
DR. MARK ASHAMALLA M.D.
Address
ALBANY VAMC 113 HOLLAND AVE,ALBANY NEW YORK 12208
Death Certificate Filed District tuber Resisterumber
•,m City, Town or Village o\h � /
❑Burial Date Cemetery or Crematory /P
❑Entombment %(t 2 � / ��ru( t`I c �? Gig— /'!- 7
Address
xY Cremation kv IS-C RIS '1 V itie
Date Place Rembved
❑Removal
and/or Held
and/or Address
i:y...
Hold
Date Point of
❑Transportation Shipment
= <T by Common Destination
Carrier
El
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to _ 1 Registration Number
Name of Funeral Home /. A V<' 'Z d L.. )K 1 y
Address.._ Scr/41220 AJ L( k L /-L/y, ik ° 1oirE- 7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human r n des rib d v • is
. Date Issued October 25,2015 Registrar of Vital Statisti es in n
(signature)
District Number )(. Place ALBANY VAMC 113 HOLLAND AVE,NEW YORK 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IoIv1!,r Place of Disposition ernst or:v.,
(address)
•
r�s
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
=;r Signature �` Title
a vRa 9
(17,104144
(over)
DOH-1555 (02/2004)