Eggleston, Richard Harold 'I 3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Pe It
Bureau of Vital Records
Name First Middle - Last Sex
Richard Harold Eggleston Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/15/2021 73 Years War or Dates 1966-1972
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
`p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide 1=1 Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 219
Burial Date Cemetery,Crematory or Facility Name
05/19/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
ElDonation
0 Removal Date Place Removed
- and/or and/or Held
- Hold Address
CO
0
O. Date Point of
U) Li Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
a Address
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/18/2021 Registrar of Vital Statistics tl'y6ertf7ndrewCurtis(Electronicaf/Signed)
(signature/
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition .S110 fl,' Place of Disposition `L
2 '66 (address)
W
to°C (section) (lot nu per).. / (grave number)
Art J
Name of Sexton or Person in Charge of Prises ti phi
� /please print/
W Signature Title L �` L
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 +3 ' a t i
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# :., 1