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Waite, Richard NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Richard Royce Waite Male Date of Death Age If Veteran of U.S. Armed Forces, 08/24/2017 72 Years War or Dates 1965-1971 Place of Death Hospital, Institution or City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Kyle Leonard MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 455 ❑Burial Date Cemetery or Crematory 08/31/2017 Pine View Crematory El Entombment Address ®Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 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 above as indicated. Date Issued 08/29/2017 Registrar of Vital Statistics e.s6ertACurtis F4ctronicaffySigned (signature) 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: Date of Disposition gill r) Place of Disposition (address) (section) j' (lot number) r (grave number) Name of Sexton or Person in Charge of Premises 4 r+s .,r. J 4.4 ii (p/ se print) Signature Title jR l; (over) DOH-1555(02/2004)