Owen, Richard NEW YORK STATE DEPARTMENT OF HEALTH r t # P
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Jeffery Owen Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 14, 2015 65 War or Dates
I. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑ Accident Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
14 Medical Certifier Name Title
Farhana Kamal, M.D. Dr.
Address
,v, ` 100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number ( ` Regis tyer
City, Town or Village Glens Falls ( AI Lj f
=•: ❑Burial Date Cemetery or Crematory
„, July 15, 2015 Pine View Crematory
❑Entombment Address
, ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
"`
, Date Point of
❑Transportation Shipment
f by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
._El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
.' Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
5 Address
136 Main Street, South Glens Falls NY 12803
% Name of Funeral Firm Making Disposition or to Whom
': Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remainszyd v dicated.
_T Date Issued 07 i26/ Registrar of Vital Statistics
.. (signature)
District Number 6O1 Place 6/4„a `%' NY
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
n Date of Disposition 07/15/2015 Place of Disposition Quaker Road Queensbury,NY 12804
t (address)
(section) A (lot number) (grave number)
c
Name of Sexton or Person in Charge of Premises ►.>{ .-- �e
(l lease print)
f.
., Signature Title ener4.414.-
(over)
DOH-1555 (02/2004)