Schermerhorn Jr, Richard NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
Richard Schermerhorn Jr. Male
!> Date of Death Age If Veteran of U.S. Armed Forces,
08 / 29 / 2015 48 War or Dates N/A
}- Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
LLI0 Manner of Death®Natural Cause 0 Accident ❑Homicide 0 Suicide �Undetermined 0 Pending
1 Circumstances Investigation
O.
tu Medical Certifier Name Title
0 Michael Sikirica MD
Mi
Address
50 Broad St, Waterford, NY 12188
ii Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs L-15o1 `-4 2 Z
' OBurial Date Cemetery or Crematory
08 / 31 / 2015 Pine View Crematory
< >UEntombment Address
QCremation 21 Quaker Road, Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
g 7and/or Address
Hold
I
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
im
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiig Name of Funeral Home Compassionate Funeral Care, Inc 00364
MI Address
>;5 402 Maple Ave. , Saratoga Springs, NY 12866
lig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
!` Permission is h obis/ ranted to dispose of the human rem/atria rfs d c ' ed abpv indicat .
imii
vi Date Issued _� 2,j I ;j Registrar of Vital Statistics r
(signature)
i District Number 4,1 5—cl1 Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
til Date of Disposition 9A lic Place of Disposition . iitU,,,J Ca.,
(address)
tit
Ir (section) /, (lot number) (grave number)
ciName of Sexton or Person in Char of Premises + L51 '
(please pent) •
W. Signature Title �b'� J/L
(over)
DOH-1555 (02/2004)