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Simpson Sr., Richard Alexander I NEW YORK STATE DEPARTMEN T Burial of Vital Records - Transit Permit Name First Middle Last Sex Richard Alexander Simpson Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 01/11/2021 81 Years War or Dates ... Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause 1=1 Accident ID Homicide ❑Suicide El Undetermined ❑Pending W U Circumstances Investigation G Medical Certifier Name Title Marvin Davidowitz MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 17 ❑Burial Date Cemetery,Crematory or Facility Name 01/13/2021 Pine View Crematory El Entombment Address lCremation Queensbury Town,New York 0 Donation Removal Date Place Removed p and/or and/or Held N Hold Address 0 d Date Point of d) ❑Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1-. Remains are Shipped,If Other than Above 2 Address EC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/12/2021 Registrar of Vital Statistics Np6ert Andrew Curtis(ECectronicaiySigned) /s/gnature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z v_ ,/� W Date of Disposition f 1PN Ili Place of Disposition !M l e•�df6.► 2 (address) W CO CC (section) p (lot number)- (grave number) Name of Sexton or Person in Charge o remises C T'I'r`- 9U Alit z (p!ase print) W Signature a Title `1wo�I" nt DOH-1555(07/18)p 1 of 2 7 Public Health Law Sec. 4145(2b) ° '` a Receipt Human remains of _i delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#