Richardson, Jon Eric NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jon Eric Richardson Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2020 73 Years War or Dates 1965-1972
IN Place of Death Hospital,Institution or
W City,Town or Village Bolton Town Street Address 26 Finkle Road,Bolton Town,New York 12814
p Manner of Death Natural Cause Accident Homicide 1:1Suicide Undetermined Pending
IL Circumstances Investigation
U
W Medical Certifier Name Title
Michael Bell MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Bolton Landing 5650 1
❑Burial Date Cemetery,Crematory or Facility Name
01/22/2020 Pine View Crematory
Entombment Address
1 Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
d Transportation Date Point of
to �
Q by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
�.. Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/22/2020 Registrar of Vital Statistics ,7od'L Connally(EYectronwaa Signed)
(signature/
District Number 5650 Place Bolton Landing, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition I /Z3 �7A Place of Disposition
2 (address/
W
N (section) (lot tuber), (grave number)
M
0 Name of Sexton or Person in Charge of Premises
( ase print/Z
W Signature Z Title
DO H-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) - _ ; 6
Receipt
Human remains of delivered on , 20_
Pine View Cemetery I `Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#''''' ' `x,