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Pennock, Richard E. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard E.Pennock Jr Male Date of Death Age If Veteran of U.S.Armed Forces, 03/12/2020 56 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation WMedical Certifier Name Title William Cleaver MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 123 ©Burial Date Cemetery,Crematory or Facility Name 03/18/2020 Pine View Cemetery Entombment Address Cremation Queensbury,New York Donation Z Removal Date Place Removed and/or and/or Held Hold Address IL Date Point of fp Transportation Q by Common Shipment 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 t- Remains are Shipped,If Other than Above 2 Address 1C W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/16/2020 Registrar of Vital Statistics W96etrAzdrewCurt&(E&tronkadStgne4 (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: H Z Date of Disposition 3 J 1 g�� Place of Disposition 21 Quarker Rd. Queensbur NY 12804 LU --- -- (address)_ W Erie 77G 1 Q (sedion) (tot number) (grave number) 0 Name of Sexton r 'rson in Charge of-Premises t se riot/ 42) /P W Signature `Z �' '�� �� Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U10 �':� Receipt Human remains of delivered on , 20 Fine View Cemetery Representing`fthe funeral home named on burial permit Official �__.__. Funeral Directors Reg.or License# PENNOCK NAME Richard E. Pennock Jr. Age:56 Lot Owner:Lauren and Devin Pennock Lot# 77G Erie Grave# 1 Case: Concrete Died:3/1 2/2 0 2 0 Interred:3/1 8/2 0 2 0 Funeral Home: Regan Denny Stafford Cemetery:pine View Pennock Owner Lauren and Devin Pennock Address Plot 7 Birdsall Road, Queensbury, NY 12804 Erie Phone # Lot # Lauran- 518-937-1156 Devin 518-681 -2282 77G Deed # Date 4167 -1/1 ti/9n2n Cost Foundation Y - N _ $650 00 Location North- Vacant South- Vacant East- Vacant West- Remarks I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULAIONS OF PINE VIEW C METERY. SIGNATURE., DATE: Record of Interments 1 6 Richard Penneck 3/12/2020 2 7 3 8 4 9 5 10 a � �- n d � e one