Odom, Dwayne NEW YORK STATE DEPARTMENT OF HEALTH 4 - ,,,.
Vital Records Section Burial - Tr sit Permit
Name First Middle Last Sex
Dwayne Joseph Odom Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/24/2014 57 War or Dates No
I— Place of Death Hospital, Institution
Z City, Town or Village City of Albany or Street Address Albany Medical Center
Ili
O Manner of Death Natural ❑ Undetermined ❑ Pending
LU ® Cause ❑ Accident El Homicide E Suicide Circumstances Investigation
W Medical Certifier Name Title
p Pauze Daniel MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101 2453
Date Cemetery or Crematory
❑ Burial 01/02/2015 Pine View Crematorium
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
9. ❑ and/or Address
}- Hold
Cl)
Q Date Point of
p. Transportation Shipment
Cl) ❑ By Common
p Carrier Destination
El Disinterment
Date Cemetery Address
ElDate Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
• Address
Ce
d. Permission is hereby granted to dispose of the human remains scr d above as indicated.
Date 12/26/2014 Registrar of Vital States t t 44'-)—:"'4-'---- .i������
Issued (signature) /
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I�t.//S Place of Disposition ZIL Cr-d• c.ldr;'
W (address)
'Li
cn
re (section) (lot number) (grave number)
0
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Name of Sexton or Person in Charge of Premises
(please print)
A
SignatureL Title CIS i WIf1v
(over)
DOH-1555 (02/2004)