Tracy, Richard NEW YORK STATE DEPARTMENT OF HEALTH c = .- v # (//c
Vital Records Section 41.. Burial - Transit Permit
Name First Middle Last Sex
Richard M. Tracy Male
Date of Death Age If Veteran of U.S. Armed Forces,
ffi 05/27/2017 58 years War or Dates
144 Place of Death Hospital, Institution or
&MitX Town oX"WilleGreenfield Street Address 1203 North Creek Rd. Lot 12 Porter Corners, NY
• Manner of Death Natural Cause Accident Homicide u Suicide 0 Undetermined 0 Pending
In Circumstances Investigation
ill Medical Certifier Name Title
John Delmonte Jr. Attending Physician
Address
3 Care Lane, Suite 300, Saratoga Springs, Ny 12866
Death Certificate Filed District Number Register Number
)0 Town oXXJ X e Greenfield 4557 15
ii❑Burial Date Cemetery or Crematory
05/30/2017 Pineview Crematorium
❑Entombment Address
:]Cremation Queensbury, N Y
Date Place Removed
Removal and/or Held
il` and/Holdor Address
0 Ca
Date Point of
IL i—i
• Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Avenue, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;; Address
Ili
0` Permission is hereby granted to dispose of the human r mains described above as indicated.
Date Issued 05/30/2017 Registrar of Vital Statistics ^ 9. 0 t(yL/\
(signature)
District Number4557 Place Greenfield
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til• Date of Disposition____iblin Place of Disposition inw{>,+ Cpreq+ow>
(address)
1LI
LC
CC (section) /� (lot number) (grave number)
CI• Name of Sexton or Person in Charge o Premises L�Pt` -t^1iif
(pl ase print)
l Signature �l Title CPEhtl( ,
(over)
DOH-1555 (02/2004)