Crofoot, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ', Burial - Transit Permit
• Name First Middle Last Sex
071 Richard J.Crofoot Male
161,
4. Date of Death Age If Veteran of U.S. Armed Forces,
8/18/2018 79 War or Dates
Place of Death Hospital, Instituti 'r
City, Town or Village Hadley Street Address olfview Rd.
• Manner of Death®Natural Cause �Accident �Homicide �Suicide Undetermined Pending
Circumstances Investigation
• Medical Certifier Name Title
rIL Edward Liebers MD
Address
Saratoga Springs,NY
Death Certificate Filed Hadle District Nl� b Regist-r Number
City, Town or Village y I
• Burial Date Cemetery or Crematory
8/21/2018 Pine View Crematory
74❑Entombment Address
®Cremation Queensbury,NY
4.1
Date Place Removed
Removal and/or Held
' and/or
Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
• Disinterment Date Cemetery Address
ReintermentEi
Date ' Cemetery Address
Ili Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St.,Lake Luzerne,NY 12846
'`g Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereb granted to dispose of the human re in described a ove as indicated.
W /
Date Issued g 21 i g Registrar of Vital Statistics ‹-,
41 / (signature)
District Number q5J 8 Place�6j/ z / '
4,4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
: Date of Dispositions-6.x-t Place of Disposition )A c, Vs C--Xed crio Y
(address)
M (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises t)eX tri-t.y d;Ft—S
(please print)
17, Signature Title C lei yraor
(over)
DOH-1555 (02/2004)