Larson, Alfred II 301
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
i Name First Middle Last Sex
Alfred J.Larson Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/12/2018 82 Years War or Dates
Place of Death Hospital, Institution or
5 City, Town or Village Albany Street Address Albany Medical Center Hospital
ci Manner of Death El NaturalCause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
et
ta Medical Certifier Name Title
0 Anna Wu MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
J City, Town or Village Albany 0101 0834
- Date Cemetery or Crematory
sue❑Burial
04/16/2018 Pineview Crematory
}El Entombment7,1 Address
}- ®Cremation Queensbury Town, New York
Date Place Removed
2❑Removal and/or Held
and/or Address
Hold
Date Point of
tuTransportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jiuson Funeral Home Inc 00885
: Address
46 Williams Street,Whitehall Village,New York 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tti
11--` Permission is hereby granted to dispose of the human remains described above as indicated.
{- Date Issued 04/16/2018 Registrar of Vital Statistics 'DanielleSGic(espie(E(ectronica1TySigned
(signature)
District Number 0101 Place Albany, New York
IF_
b I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1,
lid Date of Disposition tII13 I( Place of Disposition f�V.,_. 7,.w,rdor;�,�
(address)
in
te
to (section) l(lot number) (grave number)
dName of Sexton or Person in Charge of Premises thr•�t .- Sm.-44
(pl se print)
1 Signature �i -c— Title IYf,I TUC
(over)
DOH-1555(02/2004)