Sickles, Richard NEW YORK STATE DEPARTMENT OF HEALTH a 7
Vital Records Section Burial - Transit Permit
Name First Middle .> Last Sex
Richard W. ,Sickles Male
Date of Death Age If Veteran of U:S. Armed Forces,
0 9/01 /2 01 6 90 War or Dates WWII
{,- Place of Death Hospital, Institution or
ZCity, Tin or Village Moreau Street Address 14 Cedar Ln,Gansevoort, 1 2831
0 Manner of Death x❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tit Circumstances Investigation
a Medical Certifier Name Title
0 Denise Czwakiel PA
Address
1205 Troy Schenectady Rd. Latham, NY 12110
Death Certificate Filed District Number Register Number
City, Twitrkor Village Moreau y5(0 2 a 9
❑Burial Date Cemetery or Crematory
09/02/2016 Pine View Crematorium
❑Entombment Address gi
(Cremation 21 Quaker Rd. Queensbury, NY
Date Place Removed
Z Removal and/or Held
❑and/or Address
to
Hold
Date Point of
ti ❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB KIlmer FH 01 078
Ni Address 136 Main St. So. Glens Falls, NY 12803
iglii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'; Address
tr
LLt
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/2//40 Registrar of Vital Statistics Xt
(signature)
ER District Number y 54, 2,, Place TUC✓ d r A 0 lc e a C--
; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uI Date of Disposition cil‘/k, Place of Disposition 4AAk.i
2 (address)
Cl)ILI
CC (section) , (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /�cr rpi,r. i t/v-4 '
(*ease print)
lEf Signature Title a atilt(
(over)
DOH-1555 (02/2004)