Senese Sr. Richard NEW YORK STATE DEPARTMENT OF HEALTH y
Vital Records Section Burial -Transit Permit
• Name First Middle Last Sex
Richard R. Senese Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/28/W 111 75 years War or Dates
1.- Place of Death Hospital, Institution or
Z City, Tow il Street Address
kA fa Glens Falls Glens Falls Hospital
• Manner o eath Natural Cause ❑Accident ❑Homicide ❑Suicide ❑undetermined ❑Pending
t✓tt Circumstances Investigation
tu Medical Certifier Name Title
0 Marvin Davidowitz Md
Address
100 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Tow5tRif*Ilksttxy Glens Falls 56n1 47n
❑Burial Date Cemetery or Crematory
❑Entombment 10/31/2011 Pine View Cemetery
Address
tCv;emation Oueensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
IH Hold
N
0 Date Point of
N ❑Transportation Shipment
a by Common Destination .
Carrier
=Date Cemetery Address
Q DisintermentLi
Reinterment Date Cemetery Address
Permit Issued to • Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
I
to
rk
Permission is hereby granted to dispose of the human remains described above a indi
Date Issued 10/31/2011 Registrar of Vital Statistics %i
(signature)
District Number Place
5601 Glans Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Uk Date of Disposition '0(6 III Place of Disposition gNI,iie„J CA/yvp 1$..i
(address)
iii
IA
cc (section) /1 (lot number) (grave number)
0
itl Name of Sexton or Person in Char of Premises / hr,Si S.AL
2 (ple se print)
Signature Title etti el 10).)
AIL
(over)
DOH-1555 (02/2004)