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Whillmen, Richard A. Name First Middle Last Sex Richard A Willmen Male Date of Death Age If Veteran of U.S.Armed Forces, 04/17/2020 81 Years War or Dates Place of Death- Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 30 Ledgeview Drive,Queensbury Town,New York 12804 p Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town orVillage Queensbury 5657 77 ❑Burial - Date Cemetery,Crematory or Facility Name ❑Entombment 04/22/2020 Pine View Crematory Address X❑Cremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed Fand/or and/or Held N Hold Address r 0) ❑Transportation Date Point of a by Common Shipment Carrier Oestma i- ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Otherthan Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/22/2020 Registrar of Vital Statistics Carofine7fi(fegarde Barber(E(ectronica((ySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were dis se of in accordance with this permit on: Z Date of Disposition °q Place of Disposition i rO renaJt .2/ uee W (address/ W N (section/ (lot number) (grave number) C Name of Sexton or Person in Ch (please print) arge f Premises v�' Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 13 5 8 Receipt Human remains of delivered on , 20 %` Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#