Zekus, Richard J. r A q0
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital,Records
Name First Middle Last Sex
Richard J Zekus Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/02/2020 63 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death ®Natural Cause Accident Homicide Suicide ā¯‘Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 104
Burial Date 7PineView
emetery,Crematory or Facility Name
03/04/2020 Crematorium
Entombment Address
mCremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d Date Point of
U) ā¯‘Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St Po Box 277,Fort Ann,New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
12
W
0- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 311 110 Place of Disposition r I..i (I
Uj (address/
W
N (section) (lot'number/ (grave number)
Cr
GName of Sexton or Person in Charge of Premises ` it
Z ( ase print)
W Signature Z/ Title `
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013386
Receipt
Human remains of .;, ` ,, delivered on - 'r'J , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# -'