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Webster Jr, Richard 0 7g NEW YORK STATE DEPARTMENT OF HEALTH ' ' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Richard J. Webster, Jr. Male gi Date of Death Age If Veteran of U.S. Armed Forces, Jan. 07, 2017 46 yrs. War or Dates NO Place of Death Hospital, Institution or City, Town or Village Street Address IIIGlens Fa_11s Glens Falls Hospital 12 Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending 111 Circumstances Investigation tu Medical Certifier Name Title .1-ohn Sawyer Mn_ Address 161 Carey Rd. , Oueensbury, NY. 12804 iiiM Death Certificate Filed District Number Register Number g City, Town or Village Glens Falls 5 b 0 k ' s> ❑Burial Date Cemetery or Crematory ❑Entombment Jan. 09, 2017 PineView Crematorium Address Cremation Quaker Rd. , Queensbury, NY. 12804 Date Place Removed Removal and/or Held and/or Address U) Hold 0 Date Point of r)• Li Transportation Shipment C by Common Destination Carrier ❑Disinterment Date Cemetery Address :0 0Reinterment Date Cemetery Address Permit Issued to Registration Number Di Name of Funeral Home Mason Funeral Home 01117 ill Address 18 George St. P.O. Box 277, Fort Ann, NY. 12827 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address t 9` Permission is hereby granted to dispose of the human remains described above as indicated. iiiiiiiii Date Issued 01 /0 9/2 01 7 Registrar of Vital Statistics 1")G Aip-k. VA.)i1f (sig ature) igiiii District Number 5 © 0 1 Place 6 ' `S A\S t•\ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: tO ill Date of Disposition 111111 Place of Disposition Utttt ri r1�o��.,.i (address) iU Ul CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pr mises /�,4` t✓ S°""r'� /�� ease print) 1.11 Signature I-x Title CiO/W- (over) DOH-1555 (02/2004)