Rieks, Valerie r
NEW YORK STATE DEPARTMENT OF HEALTH 4 72
Vital Records Section Burial - Transit Permit
Rii, Name First Middle Last Sex
Valerie L. Rieks Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/23/2016 56 War or Dates
Place of Death Hospital, Institution or .36-- �, ���w,/ 14
.,Y City, Town or Village North Creek Street Address Deceased' Residence
Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
gw Medical Certifier Name Title
PAUL BACHMAN, /-- -/..,>
At
Address
3767 Main ST. Warrensburg, NY 12885
x
Death sate Filed District Number Register mber
g'' Cit 1 own§Village Q f` � g�'-
I Date
❑Burial �r Crematory
03/24/2016 /�p 1Ge Cf.L.Ploree_X:et-/ ,-1,
❑Entombment
Address '`, r��
�� ®Cremation �-�C 1.�--E� f�zi G �� � �
Date Pla -emoved
*ri❑and/or
Removal a j�f r Held
Hold Address
Date Point of
❑Transportation Shipment
z by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
7.0
❑ Reinterment Date Cemetery Address
: Permit Issued to Registration Number
t, Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
L Address
zsOde 9 Pine St/P.O. Box 455 Chestertown NY 12817
�
.ash,.
Name of Funeral Firm Making Disposition or to Whom
s Remains are Shipped, If Other than Above
$w
Address
Permission is h eby granted to dispose of the human remains de c - e above as indicated.
Re istrar of Vital Statistics
Date Issued 3 a c( i(p 9.
€z\)
(signet
: District Number 5 ,5.. place I o-ti,,A c CktcS-k2_,
Ili I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
4`6 1
4
Date of Disposition 3)?$ 1b Place of Disposition �,a Vt•• 6 t)c4,
(address)
(section) 0 pot number) (grave number)
S z Name of Sexton or Person in Charge of Premises RA Name
please print)
Signature 0 141 Title Itkoififfit
(over)
DOH-1555(02/2004)