Faughnan, Richard C. ' , 'A 4-9 Z8
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RICHARD C FAUGHNAN Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 12,2019 72 War or Dates 03/31/1967-03/21/1968
N Place of Death Hospital, Institution or
W City, Town or Village Albany Street Address DVAMC 113 Holland Avenue Albany,NY 12208
p Manner of Death W] Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Address
113 Holland Avenue Albany, NY 12208
Death Certificate Filed Alban District Number o Register Number
City, Town or Village y Q
❑Burial Date Cemetery or Crematory
December 14, 2019 pine View Crematory
❑Entombment Addre
E]Cremation btxaker Rd. QueensbtkFx9fon, X
Date Place Removed
Removal and/or Held
� and/or Address
N Hold
O Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Regan Denny Stafford Funeral Home Registration Number
Name of Funeral Home 01443
Address 53 Quaker Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i_ Remains are Shipped, If Other than Above
$ Address
W
d Permission is here y granted to dispose of the human 7ai)derrobed above as indicated.
Date Issued l �CJ Registrar of Vital Statistics Lt L
(signature)
District Number 0198 Place DVAMC, 113 Holland Avenue, Albany, New York 12208
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition IZ IIllpIN Place of Disposition.,
x (address)
� (section) lot number) (grave number)
pName of Sexton or Person in Charge of Premises "L V.- 'q
Z (plebse print)
W Signature _ r Title 2
(over)
DOH-1555 (02/2004)
i
Public Health Law Sec. 4145(2b) X 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '