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VanYperen, Richard r.-. t NEW YORK STATE DEPARTMENT OF HEALTH ti 1)6 7 Vital Records Section Burial - Transit Permit (' Name First Middle Last Sex Richard John Van Yperen Male Date of Death Age If Veteran of U.S. Armed Forces, December 1, 2016 91 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death ❑X Natural Cause ❑Accident E Homicide Suicide ❑Undetermined Pending 11 Circumstances Investigation u Medical Certifier Name Title Scott Biasetti MD Address -''? 100 Park St.,Glens Falls,NY 12801 Death Certificate Filed District Number ,�, Regist N ber f City, Town or Village Glens Falls CJ© (DO a ❑Burial Date Cemetery or Crematory December 5, 2016 Pine View Crematorium ❑Entombment Address ❑x Cremation 51 Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold CO Q Date Point of N ❑Transportation Shipment p by Common Destinatio, Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 .(1 Address 407 Bay Road, Queensbury, NY 12804 •t;:; Name of Funeral Firm Making Disposition or to Whom r,r., Remains are Shipped, If Other than Above Address i w Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ►21 £ 1 i t Registrar of Vital Statistics �'NQ.. WW1 �,�� ��" (signature) U " District Number 5 6 o r Place G S J & I 1 1V` y,' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z DispositionPlace of Disposition ,nV:t� ;ml¢ of _i W Date of /2�l �Ib P 2 (address) W CO W (section) If (lot number) (grave number) pName of Sexton or Person in Charge of Premises (L < Js.^^t� Z ` I(please print) W Signature ` 4 Title (KAI-M. (over) DOH-1555(02/2004)