Richardson, Jeffrey N
• , li y /10
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r. Jeffrey Steven Richardson Male
15 Date of Death Age If Veteran of U.S.Armed Forces,
06/17/2018 43 Years War or Dates
• Place of Death Hospital, Institution or
ro- City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
r Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
t
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 305
El Burial Date Cemetery or Crematory
06/19/2018 Pine View Crematory
pi❑Entombment Address
®Cremation Queensbury Town, New York
lia Date Place Removed
cl.❑Removal
and/or and/or Held
Tr RI Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
T Permit Issued to Registration Number
IV
Name of Funeral Home Maynard D Baker Funeral Home 01130
"� A• ddress
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
0,
Remains are Shipped, If Other than Above
Address
- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/19/2018 Registrar of Vital Statistics ,o6ertA Curtis(flectronwal ySigned)
(signature)
District Number Place
5601 Glens Falls, New York
it
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
L D• ate of Disposition (el ii Ilg Place of Disposition gtU,,, g -a4o,.
* (address)
IT
1y
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises fie >r S",,,..14-
,,„ (pliase print)
S• ignature Title arzfrotiIVIL
(over)
DOH-1555 (02/2004)