Rivette Jr, Walter NEW YORK STATE DEPARTMENT OF HEAL i 1 ! # 513
Vital Records Section Burial - Transit Permit
;: Name First Middle Last Sex
Walter L. Rivette,Jr. Male
..: Date of Death Age If Veteran of U.S. Armed Forces,
? November 14,2015 76 War or Dates
} Place of Death Hospital, Institution or
City, Town or Village Warren Street Address Glens Falls Hospital
Manner of Death
��� X Natural Cause Accident Li Homicide Suicide U Undetermined n Pending
—
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller,MD
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number (10 Regis iy nber
4-City, Town or Village Glens Falls � ) p
❑Burial Date Cemetery or Crematory
November 16, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 1--I Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
U Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
? Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address •
Permission is hereby granted to dispose of the human remains described above as indicated.
•
Date Issued E 1, 061, t5 Registrar of Vital Statistics �L V
(signatur
District Number �, I Place 6 Cv—s \\ 5 Iv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1//ts,I S Place of Disposition g,� L arril ('Drys,,
2 (address)
W
Cl)
p0 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises (Al- t
Z az (pl ase print)
Lu
Signature % Title aZ6444T7L
(over)
DOH-1555(02/2004)