Williams, Richard Earl 710
NEW YORKSTATE DEPARTMENT OF HEALTH - Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Earl Williams Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2021 65 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 149
❑Burial Date Cemetery,Crematory or Facility Name
03/18/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town, New York
Donation
ORemoval Date Place Removed
and/or and/or Held
Hold Address
0
Q. Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Date Cemetery Addres
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/18/2021 Registrar of Vital Statistics ,96ert)1nlfrew Curtis.(ElectroncallySWned)
(signature)
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:
WDate of Disposition 3(11 Ili Place of Disposition
2 (address)
W
CC (section) itt number) (grave number)
• Name of Sexton or Person in Charge of Premisesy`""
Z (pleaserint)
Title 16-�W
• Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) r-� 014642
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#