Balcom II, Russell E 41 # taa
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i.ii Name First Middle Last Sex
4 W. BALCOM II� RUSSELL Male
Date of Deathgil Age If Veteran of U.S. Armed� Forces,
68 War or Dates 1970
Mace of Death VAMC ALBANY NEW YORK Hospital, Institution or
City, Town or Village Street Address 113 HOLLAND AVE,ALBANY NEW YORK 12208
ek Manner of Death r71Natural Cause Accident Homicide 0 Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
DR.SYED KAZMI M.D.
40. 113 Holland Avenue Address Albany, NY 12208
R`�./ Death Certificate Filed Albany District Number
Re ter Number
3 City, Town or Village 198
❑BUrlaf Date 2/24/2014 Cemetery or Crematory
Pineview Crematory
:' ❑Entombment Address Queensbury, Ny
;( ['Cremation
, Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
,, Date Point of
Transportation Shipment
by Common Destination
40 Carrier
[i Disinterment
Date Cemetery Address
, Q Reinterment Date Cemetery Address
gi
eg Permit Issued to Densmre Funeral Han?, INC. Re istration Number
kr Name of Funeral Home
Address 7 Sherman Avenue Corinth, NY P2
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 remains described above as indicated.
sp
vg
im Date Issued February 21,2014 Registrar of Vital Statistics
JAMES H.ARRI 1ON VSC MANAGER
(signature)
District Number 198 Place VAMC ALBANY 113 HOLLAND AVE ALBANY NEW YORK 12208
Ir I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q/j/ty Place of Disposition '„r( ,, a,vk.-.
(address)
(section) drd
lot number) (grave number)
Name of Sexton or Person i Charge of remises r1/4,_104114
(please print)
1:A Signature -5-- Title G rr N
(over)
DOH-1555 (02/2004)