Trzaska, Richard -tom,
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NEW YORK STATE DEPARTMENT OF HEALTH ;
•
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Trzaska Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 13,2011 57 War or Dates
°'a Place of Death Hospital, Institution or
1
City, Town or Village Queensbury Street Address 155 Chestnut Ridge Road
Manner of Death i Xi Natural Cause Accident I ]Homicide Suicide Undetermined }Pending
Circumstances Investigation
tit Medical Certifier Name Title
4 , Mark Hoffman,MD
Address
Glens Falls,NY
Death Certificate Filed District Number " Reis r Number
g' City, Town or Village Queensbury,NY 5657 ,
❑Burial Date Cemetery or Crematory
❑Entombment June 17, 2011 Pine View Crematory
Address
0 Cremation Quaker Road, Queensbury, NY 12801
Date Place Removed
Z -Removal and/or Held
and/or Address
1' Hold
O Date Point of
yI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Home 01464
Address
i 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z Address
t ,
Permission is hereb granted to dispose of the human r mains described above as indicated.
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Date Issued i Co( Registrar of Vital Statistics �-�t • C8 fl A
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition (-17-30`1 Place of Disposition 1 n e ,t t ett) c-.p„nqAo r Y
W (address)
CO
LLB
(section) (lot number) (grave number)
Z Name of Sexton or P rson in Charg of Premises �` m ai>~y Zwne(tie
Z ^r (please print)
Signature Title Cr,eyne,_,,,1-/ .54-
(over)
DOH-1555(02/2004)