Powers, Paul NEW YORK STATE DEPARTMENT OF HEALTH `
Vital Records Section Burial - Transit Permit
Name F st Middle Gast Sex
7
WL.2� -2� , c `. Z M4lV--
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place Death Hospital, Institution orp k
City, Town or Village City of Albany Street Address h,
Manner of Death ❑Natural Cause Accident Homicide FjDQy,4eide Undetermined Pending
Circumstances Investigation
Medpal Certifier rr Title
Address
'< Death CertificattA Filed District 14urhber Register Number
City, Town or Village City of Albanv 101
Date Lemetery or Crematory
:>< ❑Burial 9LievJ
Ad e s
f7lCremationILA
U i
Date Place emoved
Z❑Removal and/or Held
and/or Address
Hold
0 Date Point of
WQ Transportation Shipment
fl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
[ Name of Funeral Homei/i
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
=> Permission is hereby granted to dispose of the human remains described above as i ed.
Date Issued Registrar of Vital Statistics
(signature)
District Number
101 Place Albany Police DepartmentCan-y), NY
`. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ih C
Date of Disposition�� Place of Disposition J ri G � y�.� J 4, ,
op
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises r-�k 6RV4101—
(please print)PLI Signature Title (/R-e d ;4—
DOH-1555 (10/89) p. 1 of 2 VS-61