Richardson, Gary NEW YORK STATE DEPARTMENT OF HEALTH
#'' , n70
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
GARY JOSEPH RICHARDSON Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 8, 2016 67 War or Dates US Army
} Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
ttiManner of Deathjatural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
la Medical Certifier Name Title
0 Dr Perazzelli,md
Address
Glens Falls, NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601 I
❑Burial Date Cemetery or Crematory
Janaury 11 , 2016 Pine View Crematory
i El Entombment Address
❑Cremation Quaker Road, Queensbury, NY
''' Date Place Removed
gEl❑Removal and/or Held
and/or Address
tt Hold
0
O Date Point of
Transportation Shipment
3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to- Registration Number
Name of Funeral Home Singleton Sullivan Potter 01596
Address
• 407 Bay Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above _
,'" Address
Cr
tt
CL
Permission is hereby granted to dispose of the human remains descri ed above incl. t .
iiiiii Date Issued 1/9/2016 Registrar of Vital Statistics �/ 14E G�[ " -f
giii (signature
District Number 5601 Place City of Glens Falls, NY 12801
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i Ali Ab Place of Disposition FaidiaJ C,- o�.
(address)
`.ESE
CC (section) _(lot number) (grave number)
ei Name of Sexton or Person in Charge o Premises �'+�, lAtt
2 lease print)
W. Signature Title
(over)
DOH-1555 (02/2004)