Cerosky, Richard NEW YORK STATE DEPARTMENT 91,HEALTH OD
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard A Cerosky Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. November 30, 2016
$9 War or Dates /y 5`_3 - /�j y5
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause ❑ Accident 0 Homicide El Suicide 1111 Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Michael Miles, M.D. Dr.
0 Address
100 Park STREET, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5 60 / 5 q
❑Burial Date Cemetery or Crematory
December 2, 2016 Pineview Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
im and/or Address
Hold
-
0 Date Point of •
0 0 Transportation Shipment
in by Common Destination
Carrier
Date Cemetery Address
0 ❑Disinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
x Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1. 2..) '24 ?6 Registrar of Vital Statistics
c) -1 (signature)
District Number S t'j p 1 Place Glens Falls,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 12/02/2016 Place of Disposition Pineview Crematorium
III
(address)
(section)) `/ (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises L/�n .Siy
Z ^ nfd'
lease print)
ILI
Signature a Title Ca l Pe.
(over)
DOH-1555 (02/2004)