Whiting Sr, Ricky NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
",.<: Name First Middle Last Sex
Ricky A. Whiting, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 21,2012 47 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 12 Maine Ave
Manner of Death I X,Natural Cause n I Accident I Homicide Suicide Undetermined Pending
ktt Circumstances Investigation
al Medical Certifier Name Title
0 Eric Pillemer MD
Address
Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Ranister Number
City, Town or Village Queensbury 5657 / /
❑Burial Date Cemetery or Crematory
December 28, 2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO fl Removal and/or Held
and/or Address
t Hold
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0 —
Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
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
E. Address
ix
to
'` Permission is hereby granted to dispose of the human emains describedscn alpo e as indicated.
Date Issued } a` ?Li . Registrar of Vital Statistics . . !l L ._
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed ofin accordance with this permit on:
WDate of Disposition (._Z-t . Place of Disposition �'C��,�,.Ovw C,w,.tiior,v....
2 (address)
coIll
tY (section) / (lot number)c (grave number)
O
p Name of Sexton or Person in Charge of Premises r:'1* Li-- tt^+y1�
1Z (please print)
Signature4t.L.._ Title ree-vht od
(over)
DOH-1555(02/2004)