Jakway, Richard f * . # 7+1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ` -Sex.
Richard n_ Ja kway Male
Date of Death Age If Veteran of U.S. Armed Forces,
Aug. 28, 2018 73 yrs_ _ War or Dates n/a
la,: Place of Death Hospital, Institution or
City, Town or Village :Hartford Street Address 1 443 Baldwin Corners Rd.
0 Manner of Death J Natural Cause 0 Accident Ej Homicide 0 Suicide Undetermined 0 Pending
try0 Circumstances Investigation
Medical Certifier Name Title
G Michael Sikirica Mn.
Address
50 Broad St. , Waterford, NY. 12188
Death Certificate Filed District3 /g? ? Regisr umber
City, Town or Village Hartford
:0Burial Date Cemetery or Crematory
❑Entombment Aug. 29, 2018 PineView C rematcri um
Address
;]Cremation Queensbury, NY. 12804
Date Place Removed
❑Removal and/or Held
and/or Address
F- Hold
itl
Date Point of
a 0 Transportation Shipment
Cs by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 0111 7
Address
P.O. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
Permission is hereby granted to dispose of the human rema desotiibed a fiflve as indicated
Date Issued 0 8/29/201 8 Registrar of Vital Statistics K" _ _-` ( (-- C`
(signature)
<_ 5-59
' District Number Place Town of Hartford, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
til Date of Disposition $(3a ti$ Place of Disposition 474A, A.+0"'"'"-#
2 (address)
W
C (section) (lot numbs) ( (grave number)
Ci Name of Sexton or Person in Charge of Premises t(rise ....)t',
(please print)
Signature - Title d 'AMA-
(over)
DOH-1555 (02/2004)