Schwarz, Richard VI
NEW YORK STATE DEPARTMENT OF HEALTH" f
Vital Records Section Burial Transit Permit
Name First Middle Last Sex .
Richard J. Schwarz Male
iin Date of Death Age If Veteran of U.S. Armed Forces,
06/29/2013 42 years War or Dates
PI of Death Hospital, Institution or
ujz<Y.,-MwkXeXXVjitVtkX Glens Falls Street Address glens falls hospital glens falls, n y
ill Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide a yndetermined ri❑Pending
ill ircumstances Investigation
tui Medical Certifier Name Title
Suzanne Rayeski M D
Address
170 warren st glens falls, n y 12801
Death Certificate Filed District Number Register Number
t Tov q i/i�X Glens Falls 5601 272
Eig ■Burial Date Cemetery or Crematory
['Entombment Pine View Crematorium
Address
cemation Queensbury, NY 12804
Fici
Date Place Removed
Z❑Removal and/or Held
and/or Address
H Hold
0 Date Point of
5 0 Transportation Shipment
C! by Common Destination
Carrier
❑Disinterment Date ' Cemetery Address
❑Reinterment Date Cemetery Address
Eiiip Permit Issued to Registration Number
11 Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00141
;;; Address
9 Pine Street Chestertown, NY 12817
Name of.Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ill
'`s` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/01/2013 Registrar of Vital Statistics `.A.)
(signature)
District Number Place
5601 Glans Falls /AV /a1/
>:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition l I i 113 Place of Disposition 4?jLLw ( r+..r^
2 (address)
in
t)
CC (section) (lot nu er) (grave number)
Name of Sexton or Perso in Charge of remises r inqiiii`
.Zr (plea print)
1 Signature Title *ileiAii
(over)
DOH-1555 (02/2004)