May, Richard ti
NEW YORK STATE DEPARTMENT OF MEAL H /
Vital Records Section Burial - Transit Permit
I Name First Middle Last Sex
Richard Donald May Male
7 Date of Death Age If Veteran of U.S. Armed Forces,
. 12/14/2016 76 War or Dates After 1/31/55
' -' of Death Hospital, Institution or
°r' S , Town or Village Glens Falls Street Address Glens Falls Hospital
anner of Death Q Natural Cause 0 Accident []Homicide 0 Suicide 1-1 Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name G,� 1 l� Title ��
. . tit / _,_c=',1J` 7 —0. „1-iet Adc,Irs,.... a
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' Death Certificate Filed District Number Register Number
-,-- City, (7 Town or Village I 6 I E(
❑ Date Burial 12/15/2016 rY or C�ernato
❑Entombment J " 4, C12"P /G''/./y
Address
'`'
®Cremation �� 1��� �/
Date lace moved
w"• ` Removal
; and/or and/or Held
Hold Address
Date Point of
0 Transportation Shipment
• .v by Common Destination
4>' Carrier
e Disinterment Date Cemetery Address
s ;.m
A El Reinterment Date Cemetery Address
▪ Permit Issued to I Registration Number
3 Name of Funeral Home Barton-McDermott Funeral Home, Inc. I 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address'Ts
• Permission is hereby granted to dispose of the human remains described above as indic ted.
Date Issued i"-2..I is 1 16 Registrar of Vital Statistics (A)
(sign ure)
District Number 5 bo 1 Place t&L ; �,t \,c) it..1 U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Dispositior'2//Co//(, Place of Disposition iR /1Q)1�� C. r@,GieJ rr
' (address)
lit
(section) \ of number) (grave number)
. Name of Sexton s in Charge of Premises )t,_ /r G--►'i �r-Pn c!�'�G-
�/J (please print)
fi. Signature L �%L/(-- TitleC/2.fr" ' C,
9 G�
(over)
DOH-1555(02/2004)