TenEyck, Richard _
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard B. TenEyck Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 2,2014 74 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Suzanne Ra�ski
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed I District Number Register Number
City, Town or Village Glens Falls 5601 7
❑Burial Date Cemetery or Crematory
January 6,2014 J Pine View Crematory
❑Entombment Address
x❑Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
N
0 Date Point of
a.
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
w
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1/d J i y Registrar of Vital Statistics LA) C;-.&4-y--Q,
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui Date of Disposition I Ji 114 Place of Disposition 'e,t /�
ai,,./ t.4Of�..
(address)
W
U)
(section) (I number) — (grave number)
pName of Sexton or Pers•n in Charg of Premises J6Mwf1
w � (please print)
Signature Title t MWOe
(over)
DOH-1555 (02/2004)