Rifenburg, David Douglas -- 1433
NEW YORK STATE DEPARTMENT OF HEALTH ,�_
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
David Douglas Rifenburg Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2022 77 Years War or Dates 1964-1966
1, Place of Death Hospital,Institution or
Z City,Town or Village Amsterdam Street Address 350 E.Main Street Unit 7,Amsterdam, New York 12010
ILI
p Manner of Death ❑X Natural Cause Accident nHomicide OSuicide Undetermined ❑Pending
W
C.) Circumstances Investigation
W Medical Certifier Name Title
O Timothy Riley Coroner
Address
110 Division Street,Amsterdam,New York 12010
Death Certificate Filed City Of Amsterdam District Number Register Number
City,Town or Village 2801 309
Burial Date Cemetery,Crematory or Facility Name
01/06/2023 Pine View Crematory
Entombment Address
j Cremation Queensbury Town,New York
▪Donation
-
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N -
0
Q. Date Point of
N OTransportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2023 Registrar of Vital Statistics Stefanie Genkowiczgkctronicaf Srgnea)
(signature)
District Number 2801 Place City Of Amsterdam
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z.),,!(______
W Date of Disposition 114 13 Place of Disposition --4!,,L(_
2 (address)
W
U)
Q (section) 4° (lot number) a� (grave number)
0 Name of Sexton or Person in Charge - remises L
Z (( ease print)
W Signature Title rO`'rn�
DOH-1555(07/18)p 1 of 2
IL
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#