Loading...
Dickson, Richard NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Sectiont. Burial - Trans! Permit ;qk Name First Middle Last Sex yYce6 Richard A. Dickson Male A;° Date of Death Age If Veteran of U.S. Armed Forces, <i; March 7,2013 55 War or Dates t' wz Place of Death Hospital, Institution or i City, Town or Village Bolton Street Address 14 Brook Street d" Manner of Death X Natural Cause Accident ( I Homicide Suicide Undetermined Pending Circumstances Investigation M, Medical Certifier Name Title ;C Bryan Smead ;; rJ Address :A aE;Bolton Health Center,Bolton Landing,NY 12814 Death Certificate Filed District Number Registcr,Number c, City, Town or Village Bolton 5650 C.`� ❑Burial Date Cemetery or Crematory Zdzlsis8,2013 Pine View Crematory 0 Entombment ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address F_ Hold 0 Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address r Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address . ;' 3809 Main Street,Warrensburg,NY 12885 ;` Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above (at Address Permission is hereby granted to dispose of the human re 'n escrib d above as indic "ed. _= Date Issued 3 -7gj-/` Registrar of Vital Statistics .10 ./7b li i 6/6 - , ure) - District Number 5650 Place Bolton ~ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 3-it-t3 Place of Disposition ,c7,. tu, Cr.,0„,rsl,1� 2 (address) W co 0 (section) - of number) �1 (grave number) QName of Sexton or Person in Char e of Premises At.S S par Z (please print) W Signature Title (OP A (over) DOH-1555 (02/2004)