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Baetens, Richard • % # 93i7, NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section • Burial - Transit Permit � � Name First Middle Last Sex F Richard Adrian Baetens Male r Date of Death Age If Veteran of U.S. Armed Forces, 12/06/2017 72 Years War or Dates " Place of Death` Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending Circumstances Investigation g. Medical Certifier Name Title CI William Cleaver MD , Address 1 100 Park St,Glens Falls,New York 12801 tt Death Certificate Filed District Number Register Number e City, Town or Village Glens Falls 5601 631 ❑Burial Date Cemetery or Crematory 12/07/2017 Pineview Crematorium ['Entombment Address ®Cremation Queensbury, New York Date Place Removed 1 El❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by.Common Destination Carrier El Disinterment Date 1 Cemetery Address ❑Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Radloff Funeral Home Inc 01425 Address :� -� 136 Warren St,Glens Falls,New York 12801 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. ' Date Issued 12/07/2017 Registrar of Vital Statistics cn6mj4Curtis EfectronuaaySigned (signature) } District Number 5601 Place Glens Falls, New York .F ° I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition i t J $ In Place of Disposition eN,L/,.. 4m q-tor,— (address) (section) II (lot number) (grave number) Name of Sexton or Person in Charge of Pre ises i Iva Sth+4kr 1, print) W Signature nl ( ease Title te rAet) (over) DOH-1555(02/2004)