Quirk, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
u Name First Middle Last Sex
_� Richard Phillip Quirk Male
Date of Death Age If Veteran of U.S. Armed Forces,
-y` March 24, 2014 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
�o Manner of Death J Natural Cause Accident 0 Homicide Suicide Undetermined Pending
s, Circumstances Investigation
W Medical Certifier Name Title
ilk' Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls NY 12801
Death Certificate Filed District Number �® Register Number
City, Town or Village 5 ( \ 4 J
❑Burial Date Cemetery or Crematory
March 26, 2014 Pine View Crematorium
❑Entombment Address
4? ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold Morningside Cemetery
Date Point of
-I Li Transportation Shipment
by Common Destination
Carrier
1= Date Cemetery Address
A 0 Disinterment
Reinterment Date Cemetery Address
:3 Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
'{ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2`° Address
w
G.' Permission is hereby granted to dispose of the human remains described above as indica ed.
Date Issued 3 1 2$`1/j Registrar of Vital Statistics (JOCAA..1--)--\12-
(signature
District Number 5 601 Place 6 lclN` s G ) s / i'J y
---4 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i1.-
at Date of Disposition 03/26/2014 Place of Disposition Quaker Road Queensbury,NY 12804
�� (address)
1 (section) i (lot number) (grave number)
tf
ti Name of Sexton or Person in { rge of Premises Lrr,- .r old
(please print)
U Signature .-- J - Title Liz► j ,
(over)
DOH-1555 (02/2004)