Weaver, Richard NEW YORK STATE DEPARTMENT OF HEALTH' v tLZ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Charles Weaver Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 4, 2013 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 227 Broadway Apt 1
Manner of Death IL.] Natural Cause IIIAccident ❑ Homicide ❑ Suicide ElUndetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
David M. Mastrianni, M.D. Dr.
Address
3 Care Lane Saratoga Springs, NY 12866
Death Certificate Filed District Number/ Register Number
City, Town or Village Fort Edward ' , C.f (�
❑Burial Date Cemetery or Crematory
November 6, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
a. ❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
16
OL
Permission is h e granted to dispose of the hums ains describ abo% e as Indic ted.
Date Issued // 6 /3 Registrar of Vital Statistiiel'/4
.�— � (sig to
District Numbe3)a./ Place /4 Z C_S _x__M
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/06/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
w
a (section) lot number) c (grave number)
Name of Sexton or Perso in Charge Premises rot:gist' 31n
(pie e print)
W' Signature tt
9 - Title `�El�l�D
(over)
DOH-1555 (02/2004)