Richie, Lawrence INEW YORK STATE DEPARTMENT OF HEAL-FA— l tt IL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lawrence W. Richie Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 21, 2013 70 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
O lXl Manner of Death Natural Cause n Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
in M.John Stoutenburg,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Register_umber
City, Town or Village Glens Falls,NY 5601 1
❑Burial Date Cemetery or Crematory
March 25, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
• and/or Address
H Hold
U)
O Date Point of
co ❑Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Clifford Funeral Home
Address
2 Washington Street,Rutland, VT 05701
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
w
Permission is her by anted to dispose of the human re i s de cribed a ve as indica ed.
Date Issued Registrar of Vital Statistics eV1%1—I it -('
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were ,,isposed of in accordance with this permit on:
Z
w Date of Disposition 3-16'ii Place of Disposition —P ) Cron C,,i--
2 (address)
W
CO
re (section) Ar,;(lot umber) 14_ (grave number)
QName of Sexton or Person in Charge of Premises ) S4M
Z (pl ase print)
Wzits_ ..L....„
Title C l l'1 .
Signature
(over)
DOH-1555(02/2004)