Bartlett, Richard r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
tit Richard C Bartlett Male
Date of Death Age If Veteran of U.S.Armed Forces,
k ',' 06/03/2018 81 Years War or Dates 1956-1973
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
a Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Lori Killon PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 280
al Burial Date Cemetery or Crematory,' 06/08/2018 Pine View Cemetery
❑Entombment Address
❑Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
• and/or Address
• Hold
Date Point of
8✓ ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
IV
1; Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
Address
A
-, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/05/2018 Registrar of Vital Statistics &bertA Curtis(ECectronicaltySigned)
(signature)
fj
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:
5i
ui Date of Disposition 6/8/201 8 Place of Disposition Pine View Cemetery Queensbury
(address)
ILI
Oneida #82 1
(section) (lot number) (grave number)
iD Name of Se on or Person in Charge of Premises Connie Goederf
2 (�' (please print)
w. Signature 1, e Q '�'1 Title CPmPt-c ry Superintendent
(over)
DOH-1555 (02/2004)