Duerr, Richard ''NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ig Name First Middle ast S
I \ I C1��� ADA) ' a c��7LyZ Ivx
Date of DeattyAge If Veteran of U.S. Armed Forces,
62 /2- )/J-- `73 i War or Dates S 9 - 1.Z
'RIE
Place of Death / t Hospital, Institution or
.' City Tow) r Village (/Vf L TDAJ (Street Addre 9 /! 1713 dJ.-z-.crvc"
:,z Manner of Death r, Natural Cause Ej Accident 0 Homicide 0 Suicide ri Undetermined Ei Pending
Circumstances Investigation
Medical Certifier Name ,r- Title
Jbm,„) LUi(, I�SZ�1--)1cZ r� .
Address
`.r gru �J7-. Qt,44--)s Fel,ci 1 2 /
Deat ificate Filed ! District Number R gister Number
Ci , Town Village Wt/L72.9,J I y.��(0 9 J -„.7
Date 1, 7
! - - - :t ematory //t�
Burial //J' t-,„) ui U`LJ
I Address
_ n Cremation- _ ____ __ _
Date Place Removed /
0❑Removal , and/or Held
-- and/or - - -- -- -
Address
Hold
Date - - - --,---
Point of
NQ Transportation _ j Shipment
ES by Common Destination
Carrier
Disinterment Date Cemetery Address ,
Reinterment Date , Cemetery Address
Permit Issued to Registration Number
iiit Name of Funeral Home Zaker funercil Home__ d i ) 3C)
`'_ Address
it 11 L F y etteC (+. , &Ltc.cn s bc,c.rcd ; /U M) Lk. r A- /J AZ/
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
6- Address
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued QLQP 15 Registrar of Vital Statistics C&JZ cci/C -
_ [' /(`signature) �1
!>3 District Number //^^q Place 6 i i11 o 1 W f /*()f
��Llr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
1:iJ Date of Disposition 6/1 7/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
(address)
LW S. I. 12 2
Cr (section) (lot number) (grave number)
Name of Sex .n or Person in Charge of Premises Connie L. Goedert
- (please print)
:I Signature i t V_.. .-e. c c-� Title Cemetery Superintendent
(over)
DOH-t 555 (9/98)