Morris, Richard v.
NEW YORK STATE DEPARTMENT OF HEALTH Burial - TranS�ermit
Vital Records Section
Name First Middle Last Sex
Richard S. Morris I Male
Date of Death 1 Age If Veteran of U.S. Armed Forces,
June 25,2011 77 War or Dates Korean
1.. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Westmount Health Facility _
W Manner of Death I XI Natural Cause Accident n Homicide fl Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
,01 Roslyn Socolof MD
Address
42 Gurney Lane,Queensbury,NY
Death Certificate Filed District Number 1 Register,Number
City, Town or Village Queensbury 6(0 c- 1 (gyp 6
❑Burial Date j Cemetery or Crematory
June 27,2011 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address 1
H Hold
0 Date Point of
y I (Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 1 01464
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
t-- Remains are Shipped, If Other than Above
2 Address
W �^ --- --
4 Permission is hereby granted to dispose of the human remains described ab as indicated.
Date Issued (9 r s c.y Registrar of Vital Statistics ��,(Ze" _ ------
(signature)
District Number ctE,5-) Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance' with this permit on:
w Date of Disposition �-7q-t1 Place of Disposition f?"vi-41\4 C N cfut ....
W (address)
N
IX (section) (lot num ) (grave number)
pName of Sexton or Person in Charge o Premises i►r,�' ir' aht4tt
Z (please print)
Signature �4' Title CIZ(, I'1�4td�
(over)
DOH-1555(02/2004)