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Fallon, Richard NEW YORK STATE DEPARTMENT OF HEALTH L 20( Vital Records Section Burial - Transit Permit tit Name First Middle Last Sex 9 Richard E. Fallon Male /4 Date of Death Age If Veteran of U.S. Armed Forces, October 5,2014 95 War or Dates World War H 7. Place of Death Hospital, Institution or 3 City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre Manner of Death Lry Natural Cause n Accident Ei Homicide n Suicide n Undetermined [Pending Circumstances Investigation Medical Certifier Name Title Roslyn Socolof,MD _ Address ,.'' Glens Falls,NY {; Death Certificate Filed District Number ReQistte`Ny r mber City, Town or Village Queensbury,NY 5657 S ❑Burial Date Cemetery or Crematory October 7,2014 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold Cl) o Date Point of N 0 Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ,i'; Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 0 407 Bay Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom s4 Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human r ains describe above as indicated. 6 ul g �_ 6 Date Issued t�Re istrar of Vital Statistics (signature) District Number 5657 Place Queensbury,NY 4, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 10)7 tiq Place of Disposition ,H.ury C or„-- 2 (address) W Ct (section) ! (lot number) � (grave number) pName of Sexton or Person in Charge of Premises ` tr»' ,_ �Ja Z (please print) W Signature Title e'LiEnilVit (over) DOH-1555(02/2004)