Eggleston, Richard / 3 / -
• NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . Burial - Transit Permit
110 Name First Middle r,J Last .� Sex
i c h�ei C . 4: /e /# Ai !fit A ��
Date of Death Age If Veteran of U.S. Armed Forces,
r Y a 3 Qot? (p War or Dates
W Place of Death / Hospital, Institution or
City, �SAr47 , riVP„-cis Street Address ,/W-/,Q �/ > �
a Manner of Death Q'Natural C use ❑Accident ❑Homicide ❑Suicide ❑Undetermin d ❑Pending
11 Circumstances Investigation
W Medical Certifier Name Title
44 7/ M4 � te(efi t 140.
Address
/0 C SrA . S-41--P 67;74, -_ ,/?/;(„/.x /e -r-
Death Certificate Filed (7 District Number/ Register Number
City, Towne cS 4/—'4 (®,�i,4' Q/ ,D ,
❑Burial Date ` // Ce etery or Cre atory
❑Entombment 2-0O lv r/.f✓ Le 14 vd�!'/� � -t(
Address }�
iFijiiCremation U 4 1� �y�.. R / (\I e- ,i- 4ov yxi ,..cr,
Date Place Removed
Z Removal and/or Held
g❑and/or Address
17-to
Hold
C? Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home V 6 iU S �o jt r�461/ / ift 0 a Li 5 3
Address 7 Ilke(Al haer 6 ,`�l 7 P� /
�2
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
ilk
fl Permission is hereby granted to dispose of the human rem " des ribeo as indi ted.
Date Issued k a r- O 4 Registrar of Vital Statistics
(signature)
Ili District Number . 15'b/ Place SARATOGA SPRINGS
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
Z
ILI Date of Disposition 2- Z')_0 t.e Place of Disposition Pi jt(Ej/i'—1 ( 2.1 ,,,e R 1)
(address)
lu
to
ilk (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Gs-i a --( a a;44 I
z (please print)
W.
Signature Title (I '...4c, -C) )Z
(over)
DOH-1555 (02/2004)