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Kuzmiak, Richard Steven .. A lYA. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records ,o Name First Middle Last Sex I i Male Richard Steven Kuzmiak Date of Death Age If Veteran of U.S.Armed Forces, i,{< 12/17/2020 72 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital pManner of Death ©Natural Cause ❑Accident ❑Homicide 0 Suicide 1=1 Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title 0 Alon Jacobs-friedman NP Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2564 aj ❑Burial Date Cemetery,Crematory or Facility Name 12/21/2020 Pine View Crematory .. ' Entombment Address X❑Cremation Queensbury Town,New York 1 ❑Donation oZ Removal Date Place Removed and/or and/or Held F Hold Address N 0 Date Point of N Li Transportation Shipment 5 by Common ' Carrier Destination Disinterment Date Cemetery Address , LiReinterment Date Cemetery Address 4, 0a. Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 4 Address t V 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom .F.' Remains are Shipped,If Other than Above 2 Address C W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/21/2020 Registrar of Vital Statistics tDaniet(e S Gillespie(Electronically Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 1 t.Z3.-?0 't�i Place of Disposition P the viz...) t re- (a ens) ens W CC (section) i, (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises I t e"'� 62�' (please print) Z � �� W. Title 6 re,en r `)va.� Signature DOH-1555(07/18)p 1 f 2 1 Public Health Law Sec. 4145(2b) 014314 1 Receipt Human remains of ', delivered on , 20 1 1 • Pine View Cemetery Representing the funeral home named on,buria)permit 1 Official Funeral Directors Reg.or License# / i