Eicher, Alan Dwight (1111)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alan Dwight Eicher Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2023 80 Years War or Dates
w,u Place of Death Hospital,Institution or
na City,Town or Village Queensbury Town Street Address 32 Overlook Drive,Queensbury Town, New York 12804
Manner of Death El Natural Cause Accident Homicide ESuicide ❑Undetermined In Pending
VCircumstances Investigation
{ Medical Certifier Name Title
Q Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 53
L Burial Date Cemetery,Crematory or Facility Name
04/11/2023 Pine View Cemetery
Entombment
— Address
❑Cremation Queensbury,New York
Donation
Removal Date Place Removed
... and/or and/or Held
Hold Address
CD
4 Date Point of
() Transportation Shipment
a, by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
kRemains are Shipped,If Other than Above
Address
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/10/2023 Registrar of Vital Statistics Caroline?fi(Cegarde Barber(ECectronical(ySigned)
• (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:Date of Disposition 4, l\. ;2 Place of Disposition 1 ( , C -Ji2 lL � (C�t,'\ `1n\. S i v ('V� )a �
alt-\ c (address)
UJ
(� 1"9C1 I A- 13 13
cc (section,( 1 (lot number) (grave number)
•
8 Name of Sexton or Person in Charge of Premises (. C- n I
Z (please print)
IW Signature 4,4;4. Title c�O r-.,\keC\c 1A-
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 012974
Receipt '
t
Human remains of l delivered on_ ' , 20
f 7 / '
e w Cemetery .----- Representing the`funeral home named on burial permit
cial Funeral Directors Reg.or License#
EICHER
NAME Alan Eicher Age: 80
Lot Owner: Alan & Janice Eicher
Lot# Cayuga #1 Al 3/1 4 Grave# 13
Case: Concrete
Died: 4.7.23 Interred: 4. 1 1 .2 3
Funeral Home:
Regan Denny Stafford
Cemetery: Pine View
EICHER 04!)
Owner
Alan & ice Eicher
Address Plot
32 Overlook Dr. QiiPPnsbury,NY 12And Cayuga #1
Phone # Lot #
518-792-7441 A 13/14
Deed # Date
4365 1 . 11 .23
Cost Foundation Y - N
$1400.00
Location West-vacant
EAst-Road
North-Vacant
South-Path
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
SIGNATURE: LE,� ��.�.�-- � L-�- � DATE: f` 72-0-2-3
SIGNATURE: ��.i f /GE L� �z( � `� DATE: `' ///;41z 3
Record of Interments
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2 7
8
4 9
5 10
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