Schermerhorn, Richard Paul Sr. NEW YORK STATE DEPARTMENT OF HEALTH L---F 1 Burial - Transit Permit
Bureau of Vital Records �
Name First Middle Last Sex
Richard Paul Schermerhorn Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/24/2022 78 Years War or Dates Army National Guard
1_ Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 3 Par Place A,Queensbury Town,New York 12804
p Manner of Death X❑Natural Cause Accident 0 Homicide Duicide nUndetermined El Pending
WI
0 Circumstances Investigation
W Medical Certifier Name Title
a William Borgos MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 184
X Burial Date Cemetery,Crematory or Facility Name
11/29/2022 Pine View Cemetery
Entombment
_ Address
Cremation Queensbury Town,New York
Donation
o• Removal Date Place Removed
and/or and/or Held
I-
- Hold Address
ll
0
Date Point of
U)❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 Registrar of Vital Statistics Carolinexagardi Bader(Ekctronicall SOne4
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z /o & t
W Date of Disposition ��.a9•a a Place of Disposition Chi uc�Ke � (�U�11 I / N
2 (address/ LJ
Ill/ —� ' V�j aka l
U) (section) / (lot number) (grave number)
SName of Sexton or Person in Charge of Premises an rl i�. 6-ThccI .2-{
Z (please print)
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Ill Signature Title 1., lZ
•
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
U1295;a
Receipt
Human remains of delivered on , 20
Pine Vie to Representing the funeral home named on burial permit
Offici Funeral Directors Reg.or License#
SCHERMERHORN
NAME Richard Paul Schermerho e:Sr. 78
Lot Owner: Marjorie J. Schermerhorn -
Lot# Cayuga #1 j 23 & 24 Grave# 1ELF)
Case: Concrete
Died: 1 1 .2 4.2 2 Interred: 1 1 .2 9.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View