Besthoff, Richard Ernest - -7
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Ernest Besthoff Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/24/2019 80 Years War or Dates NarI Guard
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 71 Waverly Place,Queensbury Town,New York 12804
W
p Mannerof Death ❑X Natural Cause ElAccident Homicide Suicide ❑Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
G Mark Hoffman MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 173
Burial Date Cemetery,Crematory or Facility Name
11/25/2019 Pine View Crematory
Entombment Address
x Cremation Queensbury,New York
Donation
Z ❑Removal Date Place Removed
0 and/or and/or Held
N Hold Address
O
O. Date Point of
N ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
IH Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/25/2019 Registrar of Vital Statistics Caroh'aexlkgard Bader(Electrnnicaf Sand)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1—
W Date of Disposition ll�tb uqT Place of Disposition v
(address)
W
(section/ !at number/ (grave number)
O Name of Sexton or Person in Charge of Premises
W4A (plea print)
Signature Y� Title
DOH-1555(o7/18)p t of 2
sn
Public Health Law Sec. 4145(2b) 0 13 10,
Receipt
Human remains of delivered on , 20
r'
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#