Spring, Richard IT S
NEW YORK STATE DEPARTMENT OF HEALTH ( '
Vital Records Section € . Burial - Transi Permit
Na First � Middle Last ���
Dfite of Death Age If Veter n of U.S. ed Forces,
g .....-k4� ��`
a— �.- , a/ � War or Dates'-)ZW
I—' Place of Death Hospital, Institution" ,/ /��,
City ,Town or Village City of Albany or Street Address C.4..� !/kt�, L f )
G Manner of Death Natural ���� determined ri Pending .
Lt' Cause CI ❑ Homicide IDSuicide ❑ Circumstances ❑ Investigation
0 Medical Certifier NameILI itle
Address y
� .- ��{..
Death Certificate Filed �V/ District Number Register Number
City,Town or Village City of Albany 101
Date eterylof Cremato
❑ Burial 17a i.24) I ! `i-Q- (�L(>u) u.P A y _
❑ Entombment Addre
J Cremation
4tAcill-fA,LA6 )(Lital
Date Ple Removed
Z' Removal and/or Held
Q ❑ and/or Address
F- Hold
65
0 Date Point of
a. Transportation Shipment
V) ❑ By Common Destination
p Carrier
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home ` _,L 7444_71( Oil y
Address Q—___
635-7 z-itat let, ` „i 1a5Lia
—
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
a. Permission is�ereb granted to dispose of the human remains describ o e as in at
Date o1 Registrar of Vital Statistics 6'�f�'�
Issued (signature)
District Number 101 Place Albany Police Department City of Albany, NY
I certify that the remains of the decedent identified above were disposed o n accordance with this permit on:
WDate of Disposition W.r`I 1 10t7_ Place of Disposition 'i[.z U4v L ara_
i (address)
w
N
o (section) (lot number) (grave number)
O
G (�
Z Name of Sexton or Person in Chargz1emi
ses e,/ -41flt— t h„(
(please print)
Signature ditL
Title C -
(over)
DOH-1555(02/2004)