Salmon, Richard rNEW YORK STATE DEPARTMENT OF HEALTH 4. t1
if- 36 i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
_ = Richard T. Salmon Male
Date of Death Age If Veteran of U.S. Armed Forces,
. May 6,2014 73 War or Dates
I„., Place of Death Hospital, Institution or
Z' City, Town or Village Johnsburg Street Address 217 Lane Road
14
13, Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
c i Circumstances Investigation
$ Medical Certifier Name Title
Daniel Way
Address
HHFIN,North Creek,NY 12853
1, Death Certificate Filed District Number Register Number
City, Town or Village Chester 5652 ,�
❑Burial Date Cemetery or Crematory
May 8,2014 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold
0 Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment 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-w Remains are Shipped, If Other than Above
E Address
• E 1 Permission is hereby granted to dispose of the human -m.'ns d--cr'. • . • •ve as dicated.
Date Issued 5 g //7I Registrar of Vital Statistics 4 E' / / , '
(sign ure)
District Number 5652 Place Chester
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4-1-Iq Place of Disposition - to.,
M! .tw r•y 4,--.
W (address)
co
cc
pName of Sexton or Person 'n Charge of Premises (section) 4 (lot 311.40. (grave number)
Lu
Z (please print)
Title CiWPAK
(over)
DOH-1555 (02/2004)