Mates, Richard 11/21/2013 10:39 15184895632 E- TEBBUTT FREDERICK it 70-0 FADE 01
NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit
Vital Records Section
Name First Middle Last Sex
RICHARD A. MATES MALE
Date of Death Age If Veteran of U.S.Armed Forces, .
11/19/2013 72 War or Dates
Place of Death Hospital,Institution
City,Town or Village City of Albany_ or Street Address ALBANY MEDICAL CENTER V
Manner of Death 171 Natural ❑ Accident0 Undetermined 1-7 Pending
W Cause ❑ Homicide 0 SuicideCircumstances Investigation
W Medical Certifier Name Title
p. AYMAN MORGAN _ M.D.
Address
43 NEW SCOTLAND AVE ALBANY, NY 12208
Death Certificate Filed District Number Register Number
. City,Town or Village City of Albany 101 2197
Date Cemetery or Crematory
p Burial 11/21/2013 PINE VIEW CREMATORY
❑ Entombment Address
EI Cremation QUEENSBURY, NY ,
Date Place Removed
Z Removal and/or Held
2 ❑ and/or Address .,,.,—
Hold
CT) — ,
O Date Point of
0. Transportation Shipment
r) ❑ By Common Destination
O Carrier
❑ Disinterment
Date Cemetery Address
Date Cemetery Address❑
Renterment
Permit Issued To _ Registration Number
Name of Funeral Home REGAN DENNY STAFFORD FUNERAL HOME 01443
Address
53 QUAKER RD. QUEENSBURY, NY 12804
Name of Funeral Firm Making Disposition or to Whom
t" Remains are Shipped, If Other than Above
2 Address
TPermission is hereby granted to dispose of the human remains described above as indicated.
Date 11/21/2013 Registrar of Vital Statistics (7` I "' le� e
4,11.Ar_44.4_,
Issued (si nature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit�it on:
Z Date of Disposition 1j'7Z'13 Place of Disposition '�IrtUu v.J C n4c=v�
w (address)
a
w
rn
a (section) (l/'f&iL?tv
t umber) (grave number)
0
0 \r2 Name of Sexton or Person in Charge of Premises - ✓uvii(please print)
Signature _ f Title CILEfriffg4c,
(over)
DOH-1555(0212004)