Schaefer, Richard NEW YORK STATE DEPARTMENT OF HEALTH ft. A ,.1 IT
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard L. Schaefer Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/17/2011 51 War or Dates
Pla ath Hospital, Institution or
w Cit To r Village Chester Street Address Deceased's Residence
W Manner of Death Natural Cause ❑ Accident 0 Homicide Ei Suicide n Undetermined Pending
C.) Circumstances Investigation
Ul W Medical Certifier Name Title
WILLIAM C. ORLUK, (C9 I c' - -/
Address
6223 State Rte 9 Chestertown, NY 12817
Dea ficate Filed District Numbey / , — Regis Number
Ci ,Town Village � �� l��s �,
❑Burial Date Cemet o(Crem to )
02/21/2011 U ' l� ,e i,z, d �r✓O�C li'�--
❑Entombment Address
®Cremation ave,eka,r ,c( -
az..e.ef--17
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
0 Date Point of
a,. Transportation Shipment
by Common Destination
O Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00134
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
a. Permission is her y gr ed to dispose of the human - ,Aide. de/ ' "* -bov as indiicc ed.&/.6
Date Issued j Registrar of Vital Statistics 4 M.Ar fa��^'�K. - •
(si nature)
District Number kvi Place c./x7 O-((', 4 ,Z7 '" ` 'f, e/17 --r-�
F` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition_1E8,2Z I lei;( Place of Disposition 4 rnt (1+1..? Ctivkc#ori.v,.
(address)
w
x (section) I (lot er) (grave number)
0 Name of Sexton or Per in Charge o Premises ( c4)kr �„'v'. f
Z lip (please print)
W Signature s Title (124 ma i d
(over)
DOH-1555(02/2004)