Price, Justin NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section • i
-- Name First --- Middle Last Sex
;at' /`� i+11 G� rr c e.--_ 1 M a L L.
Date of Death Age If Veteran of U.S.Armed Forces,/
3 / `a D(,,)z 0 War or Dates
Place of Death Hospital, Institution A
City,Town or Village Cites/of Albany or Street Address f'k- A^ A44 . ct _,
oManner of Death Natural Accident Homicide ❑ f determined ❑ Pending
® Cause 0 ❑ 0 Suicide Circumstances Investigation
Medical Certifier Name ,�. Title
la JC. ic,,y It-. ,.„A
to Address
Death Certificate Filed ) D,i�trict Number Register Number 1
City,Town or Village City of Albany 101
Date / Cemetery o rematory
❑ Burial g / 41 2D` 3 e V ; CcM,--1-.'�'J ._�
0 Entombment Address l/
N4 Cremation ,/ e�
Date (' Place Removed
Z Removal and/or Held
2, ❑ and/or Address
F Hold
CO
Date Point of
a Transportation Shipment
CO 0 By Common
p Carrier Destination
'
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Homee.4).e_ -�- .„`e C-_ ®o (7,11
Address /
4
/ Si.NerA.. Ave C..1,.,� *& p I 1'a.11> -
35��q ---7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
4
Permission is hereby granted to dispose of the human remains des b - ov as indicate
Date OS--DS-. 'i Registrar of Vital Statistics ----
Issued (s nature)
ti
. District Number 101 Place Albany Police Depart t City of Albany, NY
VI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition /3 Place of Disposition / 1Y.&./ r u.I adess
W
re G
(section) (lot ber (grave number)
Z` Name of Sexton or so in C Premises Said "Ost
W ` / (please print)
Signature ` /'J 4644 CIL Title it-141410X- 1)f
(over)
DOH-1555(02/2004)