Diephouse, Ralph E if ill
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ralph E Diephouse Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/08/2022 75 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
• Manner of Death 11 Natural Cause Accident El Homicide []Suicide Undetermined riPending
W Circumstances Investigation
WMedical Certifier Name Title
0 Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 537
RBurial Date Cemetery,Crematory or Facility Name
09/10/2022 Pineview Crematory
Entombment Address
QCremation Queensbury Town,New York
EjDonation
g Removal Date Place Removed
and/or and/or Held
F—
N Hold Address
0
d Date Point of
Cl)JTransportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/09/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
9� Pde ie.) C' ���
Z Date of Disposition �0Z1 Place of Disposition r /`�(
ILI (address) J
g
w
NCC (section) (lot num ) (grave number)
0 Name of Sexton or Person in Cha e of Pre ises /010'4,b
Z Pnntl
W Signature ` itt/ Title . 2041 07
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 11)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#