Hurley, Richard NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Richard Gale Hurley Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 8, 2015 69 War or Dates Navy
;., Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 11 Petrie Lane
O Manner of Death in Natural Cause I ]Accident Homicide Suicide X Undetermined Pending
Circumstances Investigation
W' Medical Certifier Name Title
• Gary Scidmore, PA-Coroner
Address
Lake George,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
January 12,2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ• n Removal and/or Held
and/or Address
H Hold
N
p Date Point of
NTransportation Shipment
p by Common Destination ,
Carrier
Li Disinterment Date Cemetery Address
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
I- Remains are Shipped, If Other than Above
a Address
C4
W
fs. Permission is hereby granted to dispose of the human remains described bove as indicated.
Date Issued l � - t-
' Registrar of Vital Statistics ` 6n�` e/1.�.�..
" (signature)
District Number 5657 Place Queensbury,NY
I H
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1/iti Ir Place of Disposition a:Ad Crr1Qt, ----
(address)
W
Cl)
r4 (section) /4„4_,(lot number (grave number)
O Name of Sexton or Person in Charge of Premises
C
(p ase print)
W Signature ( 'F-r-'-- Title atirttl it,t
(over)
DOH-1555(02/2004)