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KopperJr., Richard
if 301 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Kopper Jr. I Male Date of Death Age If Veteran of U.S.Armed Forces, 03/30/2020 57 Years War or Dates Place of Death Hospital,Institution or z City,Town or Village Glens Falls Street Address Glens Falls Hospital pMannerof Death © Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title G William Cleaver MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 150 Burial Date Cemetery,Crematory or Facility Name 04/01/2020 Pineview Crematorium Entombment Address 0 Cremation Queensbury Town,New York ❑Donation z Removal Date Place Removed Q and/or —7and/or Held to U) Hold Address aDate Point of Transportation Shipment j5 by Common Carrier Destination Disinterment Date Cemetery Address Reinterment 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 orto Whom I— Remains are Shipped,If Other than Above S Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/01/2020 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ Z/?D Place of Dis W Date of Disposition �/ position ,. �.. g /address/ W Q (section) l (lot number) (grave number) Name of Sexton or Person in Charge of P emises Z /�� (p ase print) W Signature G/` Title I DOH-1555(07/18)p 1 of 2 I I Public Health Law Sec. 4145(2b) `; 013496 Receipt Human remains of a delivered on , 20 Pine View Cemetery Representing the funeral home named on-burial permit Official Funeral Directors Reg.or License# '