Powers, Theodore fl2
NEW YORK STATE DEPARTMENT OF HEALTH . Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Theodore F. Powers Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 4, 2013 73 War or Dates 1958-1978
Place of Death Hospital, Institution or
Z City, Town or Village So. Glens Falls Street Address 20 Riverview St
p Manner of Death n Natural Cause n Accident n Homicide n Suicide + I Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
jej,v 6 1-i.+ep,S z-freie 2 D
Address
?'/ ere pAci �r /En's f,- 4211,
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls 4 5 i)�
El Burial Date Cemetery or Crematory
CI Entombment January 8,2013 Pine View Crematorium
Address
ll Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O —and/or Address
t" Hold
W
O Date Point of
n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
• Address
IY
W
O. Permission is hereby granted to dispose of the human ains descri above asin[dicated.
Date Issued I 1 .7 I a 013 Registrar of Vital Statistics C�
(signature)
District Number 1-6 ak4 Place South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU &ANDate of Disposition k -�►-k3 Place of Disposition Cr rA—
W (address)
U)
(section) Arolii_(lot number)C- (grave number)
ra Name of Sexton or Person in Charge of Premises twit
(please print)
W i
Signature �_ Title Cttiwriloti
(over)
DOH-1555(02/2004)