Luther, Richard t , > 'it
NEW YORK STATE DEPARTMENT OF HEALTH BUrIaI _ Transit Permit
Vital Records Section
Name First Middle Last Sex
Richard Kent Luther Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 17, 2011 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 3 Sunnyside Road
W Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
ELICircumstances Investigation
WW Medical Certifier Name Title
W,
Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number R ister Number
City, Town or Village , Ce c' -6 c
❑Burial Date Cemetery or Crematory
August 22, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
E Hold
CO Date Point of
E. 0Transportation Shipment
CO by Common Destination
O Carrier
Disinterment Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
IX
11.. Permission is hereby granted to dispose of the human reln3ins described a ve as indicated.
Re istrar of Vital Statistics
Date Issued%'�-c}l�}p l I g - G�- C.A • /Luz---,
r--~ (signature)
District Numbe fl Place 1 0 �_,r-, O 1_D,'—sk
I certify that the remains of the decedent identified above were disposed of in accc d. xx a with this permit on:
W Date of Disposition 110111 Place of Disposition )I E .Val-) antter t
2 (address)
W
;, (section) (lot nuer) (grave number)
ci Name of Sexton or Pers in Charge of emises a,:vv,.,ph, ,a•t
(please print)
W Signature Title C1la!YAW_
9 �'
(over)
DOH-1555 (02/2004)