Bartlett, Richard ,.- 1 377
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
::: Name First Middle Last Sex
Tr:..
:r::• Richard J. Bartlett Male
rj ; Date of Death Age If Veteran of U.S. Armed Forces,
*f: May 6, 20152
89 War or Dates
z Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 2 Potter Street
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
igi Medical Certifier Name Title
Suzanne Blood,MD
r:r Address
Queensbury,NY
Death Certificate Filed District Number Register Number
re)'r City, Town or Village Glens Falls,NY 5601 2. 4 0
❑Burial Date Cemetery or Crematory
May 26, 2015 Pine View Crematory
❑Entombment Address
❑X Cremation Quaker Road, Oueensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
F Hold
V)
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
': Permit Issued to Registration Number
j;a
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
''•'• Address
• 407 Bay Road, Queensbury, NY 12804
s1 Name of Funeral Firm Making Disposition or to Whom
' ' Remains are Shipped, If Other than Above
Address
c&<': Permission is hereby granted to dispose of the human remains descriri,zil ;abov as ' i ated.
kf : Date Issued 5/Q )155 Registrar of Vital Statistics iZ���r1 ��-
(signature)
District Number 5601 Place Glens Falls,NY
FI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z pp
w Date of Disposition 3I�1i6 Place of Disposition if►nuU-i (n•- orw-
2 (address)
W
Cl)
O (section) gr�lot dumber) (grave number)
Q• Name of Sexton or Person in Charge of Premises e p�C'
WZ r /j (plebse print)
Signature 4 //?— Title ritrovw
(over)
DOH-1555(02/2004)