Mergendahl, Richard • ,t _ 4e !Z3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Mergendahl Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/22/2020 66 Years War or Dates 1978-1981
�., Place of Death Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 149 Traver Road,Wilton Town,New York 12831
`p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide Ei Suicide ❑Undetermined ❑Pending
C) Circumstances Investigation
W Medical Certifier Name Title
John Delmonte MD
Address
3 Care Lane,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Gansevoort 4569 51
❑Burial Date Cemetery,Crematory or Facility Name
11/24/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
EiDonation
Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
(I) ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/24/2020 Registrar of Vital Statistics Susan Ballwin(EI ctronica*Srgned)
(signature)
District Number 4569 Place Gansevoort, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
016--Z Date of Disposition III 71 I70 Place of Disposition
2 (address)
W
CC (section) (Qt number/ (grave number)
°C �r., t_- S,lt
0 Name of Sexton or Person in Charge remises
(plciese print) fin,
W Signature C� �� Title tl/Y1
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
1
, r.
Human remains of ' i ' delivered on , 20
l /
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#