Valmore, Richard NEW YORK STATE DEPARTMENT OF HEALTH 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard L. Valmore Male
Date of Death Age - If Veteran of U.S. Armed Forces,
01/26/2013 73 years War or Dates 1958-1962
Place of Death Hospital, Institution or
W gi0aTown or X0(4N0( Clifton Park Street Address 3 Stratford Court
p Manner of Death 0 Natural Cause ❑Accident El Homicide ❑Suicide El Undetermined ❑Pending
W Circumstances Investigation
tu Medical Certifier Name Title
d Doyle,Todd Physician
Address
400 Patroon Creek Blvd., Suite 1, Albany, Ny 12206
Death Certificate Filed District Number Register Number
400( own or UMW Clifton Park 4552 9
❑Burial Date Cemetery or Crematory
❑Entombment 01/29/2013 Pine View Cemetery
Address
[,Cremation Queensbury, Ny
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e dace Removed,
❑Removal and/or Held
and/or
Address
CO
Hold
0 Date Point of
05 El Transportation Shipment
in by Common __ Destination
Carrier
Disinterment Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny D Stafford Funeral Home 01443
Address.
53 Quaker Road, Queensbury, Ny 12804
Name-pt.-Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address -
"' Permission is hereby granted to dispose of the human(emains des ibe• - . •ve a;, dic- d.
Date Issued 01/28/2013 Registrar of Vital Statikih,c //� i _�L/i� ����
' (signature)
District Number 4552 Place Clifton Park
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k p�
Ui Date of Disposition +-30�13 Place of Disposition .wlltila Cwrctif we--
(address)
11,1
CC (section) (lot number) r (grave number)
CIName of Sexton or Person in Charge . Premises Aii-Vtia-- 4z (pase print)
Signature Title CeeiviYiil1�
(over)
DOH-1555 (02/2004)