O'Keefe, Richard NEW YORK STATE DEPARTMENT OF HEALTH rn
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Richard F. O'Keefe Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 8, 2016 85 War or Dates 1950- 1953
} Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address Stanton Nursing & Rehab Centre
a Manner of Death uLiNatural Cause Accident ❑Homicide Suicide ❑Undetermined n Pending
t Circumstances Investigation
Medical Certifier Name Title
a '(,A(I C\ (.J3\oc 0,(- 7
Address
flq 3 (rnan Ne.
Death Certificate Filed District Number Rster Number
City, Town or Village Queensbury,NY 5657 11
❑Burial Date Cemetery or Crematory
April 11, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
! Hold
Cl)
O Date Point of
N ❑Transportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
<= Permit Issued to Registration Number
r Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: Address
U i
13. Permission is hereby granted to dispose of the human remains described above a/ss indicated.
Date Issued `'i 1 11 1601(p Registrar of Vital Statistics �-'( . C -�/1-4--"-....
(signature)
District Numbe Place
�c� I , 0-' QU_ _r .s
I certify that the remains of the decedent identified above were disposed of in acco ance ith this permit on:
W Date of Disposition ii(l31i6 . Place of Disposition g"tV Cn +1bn...
W (address)
Cl)
(section) (grave number)
p• Name of Sexton or Person in Charge of Premises iztt_ootnumbet
iv+�
Z ;lease print)
W Signature /� .A1 Title (1144i4t`7
(over)
DOH-1555(02/2004)