Smith, Richard L 1 01SZ-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section _ Burial - Transit Permit
Name First Middle Last Sex
Richard Paul Smith Male
Date of Death Age If Veteran of U.S. Armed Forces,
4 dj 02/12/2018 74 War or Dates Navy
ZPlace of Death Hospital, Institution or
i City, Town or Village Queensbury,NY Street Address 7 Foster Ave. Queensbury,NY
Manner of Death Natural Cause ❑Accident El4omicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Munro MD
Address
6 Hearts Way Queensbury, NY 12804
'3 Death Certificate Filed District Number R ister Number
City, Town or Village Town of Queensbury,NY ( Lp5 p)
❑Burial Date Cemetery or Crematory
02/14/2018 Pine View Crematory
ID Entcaibment Address
®Cremation Quaker Rd.,Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
141 407 Bay Rd.,Queensbury NY 12804
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 bove as indicated.
�,,Date Issue ) 1 Li)c .ol Registrar of Vital Statistics L . � /-_____
(signature)
District Number S''(dc--Th Place I 0 LA--r\ 6 -C ., Ca , 1
1.-" I certify that the remains of the decedent identified above were disposed of in accorda�. with this permit on:
6 Date of Disposition s-/I5 00 i' Place of Disposition Pine, V>c.w C re.,mac r y
IL (address)
CO
re (section (lot number) (grave number)
QName of Sexton or Person in Charge of Premises j t_r- a r
6 (please print)
Signatur/ ). Title Cre. &;+cr
(over)
DOH-1555(02/2004)