VanDusen, Jr. Richard gfr c
NEW YORK STATE DEPARTMENT OF HEALTH `��
Vital Records Section Burial - Transit Permit
rY Name First Middle Last Sex
Richard C. VanDusen,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 6,2012 77 War or Dates Navy
Place of Death Hospital, Institution or
Z: City, Town or Village Queensbury Street Address 995 West Mountain Road
Manner of Death I Xi Natural Cause Accident [ 'Homicide Suicide [ +Undetermined Pending
14.1 Circumstances Investigation
CI Medical Certifier Name Title
4, Christopher Hoy,MD
Address
Glens Falls,NY
Death Certificate Filed District Number R gist_ er Number
City, Town or Village Queensbury,NY 5657 (3
❑Burial Date Cemetery or Crematory
❑Entombment November 13, 2012 Pine View Crematory
Address
DI Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
E Hold
N
0 Date Point of
ft I i Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
Address
i 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
t. Remains are Shipped, If Other than Above
Z Address
:tar;
tti,
CI, Permission is hereby granted to dispose of the human remains described a o e as indicated.
Date Issued 1.) 1 n ) ,),4, Registrar of Vital Statistics crn
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition j I JS)11_ Place of Disposition -PINPU1.v (., elller,+ti.
LLJ (address)
CO
(section) (1Qt number) (grave number)
p Name of Sexton or Person in Charge of remises �,s-}i�L..- �h��
Z lease print)
WifiL,
Signature Title C(ttivtrytTal,
(over)
DOH-1555(02/2004)