Schenk, Richard NEW YORK STATE DEPARTMENT OF HEALTH t # 2 (oil
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Max Schenk Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 17, 2011 29 War or Dates
I- Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
IM 1.11
Manner of Death❑ Natural Cause ❑ Accident ❑Homicide Q Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
Ili Medical Certifier Name Title
CI Paul Backman, M.D. Coroner' s Physician
Address
3767 Main Street Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, RowacorA/dlac Glens Falls 5601
❑Burial Date Cemetery or Crematory
May 23, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
z ❑ Removal Date Place Removed
and/or Held
0, and/or Address
H Hold
T Date Point of
�'❑Transportation Shipment
CO by Common Destination
t Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
Ell Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
tX
W:
CLPermission is hereby granted to dispose of the human remains described above as in icated.
Date Issued 5) 2 O l t / Registrar of Vital Statistics V)p. �
`5Lk-A
(signature)
District Number 5601 Place City of Glens Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition c'Z5-il Place of Disposition !k tj to , Orin aitOtir....
ill
(address)
CO
C (section) /� c lot number (grave number)
g Name of Sexton or Pers n in Charge o Premises hrtjt trrtit.
Z (please print)
tJ.i,'' Signature .1 Title Cz r1A=a(L,
(over)
DOH-1555 (02/2004)