Riecker, Robert It 31 V
NEW YORK STATE DEPARTMENT OF HEALTH f - k Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Robert Riecker Male
Date of Death Age If Veteran of U.S.Armed Forces,
July 21, 2012 54 War or Dates No
1- Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
GManner of Death Natural ❑ Undetermined ❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
W' Medical Certifier Name Title
p Timothy Cavanaugh Coroner
Address
112 State Street, Albany, NY 12207
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1415
Date Cemetery or Crematory
❑ Burial July 25, 2012 Pine View Crematorium
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
H Hold
U)
O Date Point of
d Transportation Shipment
co' E By Common a Carrier Destination
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine Street, Chestertown, NY 12817
HName of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
* Address
Lt
W;
a- Permission is hereby granted to dispose of the human remains described abos irulicatec� ��
Date July 25, 2012 �'Registrar of Vital Statistics {{��y��// - v
Issued (signature) /
District Number 101 Place City of Albany, NY Ia,,0%
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 7'Z6-it Place of Disposition 1/a0tvJ (-i�►�'�r.,,..-
LLI (address)
w
co
ce (section) (lot number (grave number)
O •
0
Z Name of Sexton or Person in Charge of Premises g„Sty4r- 1M' 'w' (please print)
Signature Title
9 ("tePqTOlt
(over)
DOH-1555 (02/2004)