Rucker Sr, Joseph s A s1
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section � Burial - Transit Permit
Name First Middle Last Sex
Joseph W. Rucker,Sr.,MD Male
r... Date of Death Age If Veteran of U.S. Armed Forces,
: :; August 6,2016 93 War or Dates World War II
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 7 Prospect Street#30
g Manner of Death X Natural Cause n Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Ei Michael Bell,MD
:ii:' Address
Warrensburg,NY
..4. Death Certificate Filed District Number Register Number
:� City,
ty, Town or Village Lake George 5620 /Q
❑Burial Date Cemetery or Crematory
August 9, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
(i)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home _ 01443
Address
' 53 Quaker Road, Queensbury,NY 12804
: Name of Funeral Firm Making Disposition or to Whom
>r:+ Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hu ains described above as indicated.
:e.: /
Date Issued — [ & Registrar of Vital Statistics 6cq�'—
r (signature)
District Number 5620 Place Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /►
w Date of Disposition t III((f Place of Disposition gat—/ rrhytr A.✓
2 (address)
W
U)
1Z (section) 1 i(lot num )t.4117 (grave number)
Q Name of Sexton or Person in Charge of Premises A'
`Z 1 (please print)
Signature 4 Title kc`r`ilat
(over)
DOH-1555(02/2004)