Richardson, John Henry NEW YORK STATE DEPARTMENT OF HEALTH tf
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
JOHNHENRY RICHARDSON Male
Date of Death Age If Veteran of U.S. Armed Forces,
February n16, 1'998 68 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident 0 Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Lusignan Pringle, M.D.
Address
102 Park St GF, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
Date Cemetery or Crematory
❑Burial February 18, 1998 Pine View Crematory
I--� Address
�dCremation Quaker Rd Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
�.. and/or Address
Hold
Q Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan, MInahan & Potter Funeral Home 01837
Address
407 Bay Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ii Address
Z.
Permission is hereby granted to dispose of the human remains described ab e a i ted.
G
Date Issued 2/17ig/98 Registrar of Vital Statistics
(signature)
District Number 5601 Place City of Glens Falll, NY 12801z
I certify that the remains of the decedent identified a!)ove were disposed of in accordance with this permit on:
r ��= W ere- ma.To,^Y
LU
Date of Disposition Place of Disposition P/`(4
(address)
LLI
(section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises M I C h 14 Of �.cAe Z
g (please print)
W Signatureaagyka�
Title c r f'_on a Tor'J 4SS J�
`-I-1555 (10/89) p. 1 of 2 VS-61
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