Straight, Richard NEW YORK STATE DEPARTMENT OF HEALTH- 1 LI 0
Vital Records Section Burial - Transit Permit
Name Fir ichard Middle_ b sight Sex Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/22/2013 51 years War or Dates
}. Place of Death Hospital, Institution or
W City, 10W((o 6 Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
MI Circumstances Investigation
til Medical Certifier Name Title
Del Giacco Md
A4 rMsyrtle St,
Death Certificate Filed District Number Register Number
City, ThWonfaircfi Saratoga Springs 4501 48
❑Burial Date Cemetery or Crematory
01/24/2013 Pineview Crematorium
['Entombment
Address
`'Cremation Queensbury N Y . •
Date Place Removed
Z Removal and/or Held
2❑and/or Address
N Hold
0
O Date Point of
5 Transportation . Shipment
Li by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
giE Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
111
tip.
Permission is hereby granted to dispose of the human rema' scri ed above as indicated.
Date Issued 01/24/2013 Registrar of Vital Statistics r.
(signature
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ili
J Crust.
Date of Disposition I-2��� Place of Disposition .4L r�ci>ri+••-
(address)
In
0
CC (section) I (Ipt umber) ,,11 (grave number)
Name of Sexton or Person in Charge f Premises r�s S0^�(C(
Ci (phase print)
11 Signature AIL Title ('It gm>tt'AL
(over)
DOH-1555 (02/2004)