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Ringer1V, Richard William Henry tt I NEW YORK STATE DEPARTMENT OF HEALTH • Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard William Henry Ringer IV Male Date of Death Age If Veteran of U.S.Armed Forces, 12/22/2020 3 Mos.24 Days War or Dates F Place of Death Hospital,Institution or WCity,Town or Village Hebron Town Street Address 59 Thunder Way,Hebron Town,New York 12865 p Manner of Death El Natural Cause ©Accident Homicide 1=1 Suicide Undetermined EI Pending ILI Circumstances Investigation W Medical Certifier Name Title G Wesley Perry Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Salem 5760 9 ❑Burial Date Cemetery,Crematory or Facility Name 01/04/2021 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation 6 El Date Place Removed and/or and/or Held N Hold Address 0 d. 1-1 Date Point of U) ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped,If Other than Above E Address CC W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/04/2021 Registrar of Vital Statistics (Dorothy Worthington(E(ectronica((ySigned) (signature) District Number 5760 Place Salem, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W~ I ' Date of Disposition 1151 Zj Place of Disposition �„� 2 (address) W cc N (section) t (lot number) (grave number) ci Name of Sexton or Person in Charge of Premis 1A1 �t Z (pi as rint) W Signature Title (Pr 444Vit DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014374 Receipt Human remains of delivered on !" r , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# j;'/