Morehouse, Ricky t , 11- ch,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
>} Name First Middle Last Sex
Ricky A. Morehouse Male
Date of Death Age If Veteran of U.S. Armed Forces,
=R 3° September 20,2016 56 War or Dates
: Place of Death Hospital, Institution or
City, Town or Village Chester Street Address 240 Hardscrabble Road
Manner of Death X Natural Cause 1 I Accident 1 1 Homicide Suicide I I Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
xG, Paul Bachman
Address
HHHN,Warrensburg
Death Certificate Filed District Number Register Number
City, Town or Village T/O Chester 5652 10
❑Burial Date Cemetery or Crematory
Entombment September 22,2016 Pine View Crematory
11 Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment
Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
5 Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
xg-'_ 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
`3 Remains are Shipped, If Other than Above
Address
U
Permission is hereby
y granted to dispose of the human remai c�e r ribed above as indicated.
Date Issued 9 �( -Qo(0 Registrar of Vital Statistics I
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District Number 3 6,5c;, Place p r_t• Ci,(IN `4-e; --
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
W Date of Disposition ¶j Z2.(j(, Place of Disposition in1 UiN1 LPgmQ'oeNA—
M (address)
W
Ca
Ce (section) (lot number) < (grave number)
pName of Sexton or Person in Charge of Premises / (11\I r Se4,td1
Z ��� � 2t P(p/ ase print)
W q� Title C I1 TL
Signature 7
(over)
DOH-1555 (02/2004)