McCarthy, Richard NEW YORK STATE DEPARTMENT OF HEALTi-FS - 4 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Eugene McCarthy Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 15, 2015 95 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 12 Wilson Street
tManner of Death ❑X Natural Cause n Accident ❑Homicide n Suicide n Undetermined n Pending
ILICircumstances Investigation
Medical Certifier Name Title
Dr Dan Sooriabalan,MD
Address
Queensbury,NY
Death Certificate Filed District Number er Number
City, Town or Village Queensbury,NY 5657
El Burial Date Cemetery or Crematory
April 17, 2015 Pine View Crematorium
❑Entombment Address
ID Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
O
and/or Address
H Hold
Cl)
O Date Point of
N ❑Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
Permission is hereb granted to dispose of the human remains described above as indicated.
Date Issued �lC Registrar of Vital Statistics CA.__ --
17,44
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Lu Date of Disposition 4 (IDiir Place of Disposition fqa r. �,
(address)
W
U)
W (section) /`(lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises L l rs
Z / (ple se print)
Signature Title (i ty
�
(over)
DOH-1555(02/2004)