Acosta, Ricardo Rafael , LF
NEW YORK STATE DEPARTMENT OF HEALTH `
LF„,. Burial - Transit Permit
Bureau of Vital Records —
Name First Middle Last Sex
Ricardo Rafael Acosta Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/18/2022 63 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Clifton Park Town Street Address 8 Woodstead Road,Clifton Park Town, New York 12019
p Manner of Death ❑x Natural Cause IllAccident Ei Homicide OSuicide nundetermined Pending
W
C.) Circumstances Investigation
W Medical Certifier Name Title
G Maeve Dargush NP
Address
43 New Scotland Avenue MC7,Albany,New York 12203
Death Certificate Filed Town Of Clifton Park District Number Register Number
City,Town or Village 4552 121
Burial Date Cemetery,Crematory or Facility Name
SEIM 10/21/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
60Removal Date Place Removed
and/or and/or Held
~ Hold Address
CD
0
Date Point of
Cl)❑Transportation Shipment
p by Common
Carrier Destination
Ei
Disinterment
Date Cemetery Address
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
XAddress
Q
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/21/2022 Registrar of Vital Statistics Teresa 03ro6ston(ECectronicaltySigned)
(signature)
District Number 4552 Place Town Of Clifton Park
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition /O-2z-Zo2L Place of Disposition ,n)e ii�e,.J C'f-GA1n ``((
2 (address')
W
Cl) (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premi I,4 f�.1.ai'/ "' O r
z
(please print)
W Signature `' / Title 1. tT'vic-r-
DOH-1555(07/18)p 1 of 2
f'Q
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#