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Hajeck, Richard A
(DI t- —N 0 NEW YORK STATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit Bureau of Vital Records . Name First Middle Last Sex Richard A.Hajeck Male Date of Death Age If Veteran of U.S.Armed Forces, 09/29/2023 80 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc ILI p• Manner of Death ❑X Natural Cause IllAccident I (Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title G Nicole Humiston NP Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 84 Burial Date Cemetery,Crematory or Facility Name 10/02/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0 El Removal Date Place Removed and/or and/or Held ~ Hold Address N 0 a Date Point of Cl)OTransportation Q by Common Shipment Carrier Destination — O 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 f. Remains are Shipped,If Other than Above E Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/02/2023 Registrar of Vital Statistics Attlee_Waiting(Electronrcaf Srgnerl) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l— � Z▪ Date of Disposition I v 12 l Z? Place of Disposition 1 =+JE V L•J C lZ of r tcA 2 (address) W Cl)CC (section) A . (lot number (grave number) GName of Sexton or Person in Charge Premises t t �-- - Z (please prin W Signature i Title JJJ fP4_ _ DOH-1555(07/18)p 1 of 2 01, 17 2 Public Health Law Sec. 4145(2b) Receipt 1 Human remains of delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#