Cruickshank, Richard NEW YORK STATE DEPARTMENT OF HEALTH w ti .137
Vital Records Section Burial - Transit Permit
1:: Name First Middle Last Sex
rzA Richard E. Cruickshank Male
Date of Death Age If Veteran of U.S. Armed Forces,
'-N. July 8,2014 77 War or Dates
Place of Death Hospital, Institution or
`Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital
04
1 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
L Circumstances Investigation
Medical Certifier Name Title
Frances C. Bollinger
}# Address
161 Carey Rd.,Queensbury,NY 12804
• Death Certificate Filed District Number Register Number
• ] City, Town or Village Glens Falls 5601 5911
❑Burial Date Cemetery or Crematory
❑Entombment July 9, 2014 Pine View Crematory
Address
El Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z
I ]Removal and/or Held
and/or Address
t Hold
O Date Point of
0.
co Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
g• '_ Permit Issued to Registration Number
s Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
egg; 3809 Main Street,Warrensburg,NY 12885
=:Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
• Address
AU
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued? 1 ci I 1 L-j Registrar of Vital Statistics (J-J CA.- ' i\.)
4.2 (signature)
--' District Number Place L?
3 P 5601 Glens Falls' r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition 1-11-11( Place of Disposition 1210cVit ..d a rctotic,--
LJJ (address)
Cl)
0: (section) Qot number) (grave number)
p Name of Sexton or Person in Charge of Premises (j n s ._ r't
Z (pledse Q„
au
prin
Signature /, 4-...... Title C Kn' t
(over)
DOH-1555 (02/2004)