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Richardson, Jeffrey Paul NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jeffrey Paul Richardson Male Date of Death Age If Veteran of U.S.Armed Forces, 01/14/2021 66 Years War or Dates ▪ Place of Death Hospital,Institution or Z City,Town or Village South Glens Falls Village Street Address 3 Newton Street,South Glens Falls Village,New York 12803 Lp Manner of Death ©Natural Cause Accident Homicide El Suicide El Undetermined El Pending Circumstances Investigation Ui Medical Certifier Name Title David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village South Glens Falls Village 4524 3 EiBurial Date Cemetery,Crematory or Facility Name 01/19/2021 Pine View Crematory Entombment Address X❑Cremation Queensbury Town,New York ❑Donation O Removal Date Place Removed and/or and/or Held f- Hold Address 0 a Date Point of CD ❑Transportation by Common Shipment Carrier Destination ElDisinterment 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 H Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/17/2021 Registrar of Vital Statistics Shannon Killeher(ECectronica1TySigned) (signature) District Number 4524 Place South Glens Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this per ' ZLW Date of Disposition I Zo f Z I Place of Disposition IL (address) LL] O (section) I/ot number) c (grave number) Name of Sexton or Person in Charge o Premises �� o+tHNt 1rr Z (please riot) W Signature Title Cn' �� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) " Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#