Simpkins, Wyman NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section { Burial - Transit ief mit
Name First Middle Last Sex
Wyman Simpkins Male
Date of Death Age If Veteran of U.S. Armed Forces,
06 / 30 / 2013 60 War or Dates N/A
is Place of Death Hospital, Institution or
City, Town or Village Albany Street Address Albany Medical Center Hospital
U.Ia Manner of Death® Natural Cause 0 Accident E Homicide ❑Suicide ❑ Undetermined ❑Pending
UI Circumstances Investigation
ui Medical Certifier Name Title
II Shawna Suchecki D.O.
Address
AMCH 43 43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village Albany 101 1310
0Burial Date Cemetery or Crematory
a �Ve>F.,/, ?di 3 77%ne.v1�''''Cr'em.2. 0 r-/
❑Entombment Address ilT //
®Cremation ,,�c-ns b 4.,rXt ti y
Date Place Removed
Z Removal / / and/or Held
0❑and/or Address
i=` Hold
CO
0 Date Point of
❑Transportation Shipment
a by Common Destination
ig Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
i
Permit Issued to 1 Registration Number
Name of Funeral Home Compassionate Funeral Care 00346
Address
402 Maple Ave.,Saratoga Springs,NY 12866
ii Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
ill
Permission is hereby granted to dispose of the human remains described above as indicated.
Mi Date Issued 7/2/2013 Registrar of Vital _
(signature)
District Number 101 Place Albany , Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lif
W Date of Disposition 1-g13 Place of Disposition wawc its rtr-,
2 (address)
#J1
40.
ir (section) 4 (lot number) / (grave number)
4 I�_ StheNttt—
C Name of Sexton or Person ip Char of Premises
(please print)
Signature /frt Title•
(over)
DOH-1555 (02/2004)