Coulman, Ace 1
NEW YORK STATE DEPARTMENT OF HEALTH h , # 353
Vital Records Section Burial - Transit Permit
;µ# Name First Middle Last Sex
Ace Richard Coulman Male
_ ,° Date of Death Age If Veteran of U.S. Armed Forces,
July 9,2012 4 mos War or Dates
g Place of Death Hospital, Institution or
eCity, Town or Village Albany Street Address Albany Medical Center Hospital
▪ Manner of Death X Natural Cause I 'Accident I !Homicide Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
=fl Hedge Dr.
Address
Albany Medical Center,Albany,NY
Death Certificate Filed District Number Register Number
t
City, Town or Village Albany Albany // /,3a g
❑Burial Date Cemetery or Crematory
July 10,2012 Pine View Crematory
❑Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
t Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
,, 3809 Main Street,Warrensburg,NY 12885
'' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
A Address /
ti
, , ] Permission is hereby granted to dispose of the human remains described above as indicated.
:I Date Issued 7f'y/ o/(9... Registrar of Vital Statistics &ilia12.0*
xz=] (signat e)
District Number Albany Place Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 11 it l IL Place of Disposition V .i1 H„ —t r`I Cr
W (address)
N
CC (section) \
f (lot number) (',�� (grave number)
pName of Sexton or Person in Charge of Premises
'Z a If�.r 5(please print)
Signature4 L- Title CptwyitH;OYl
(over)
DOH-1555 (02/2004)