Mattison, Richard John it it,-7
NEW YORKSTATE DEPARTMENT OF HEALTH •
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard John Mattison Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/11/2021 65 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause El Accident 0 Homicide Suicide ❑Undetermined Ej Pending
UCircumstances Investigation
W Medical Certifier Name Title
0 Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 211
Burial Date Cemetery,Crematory or Facility Name
05/13/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
d Date Point of
U) L j Transportation Shipment
Q by Common
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward, New York 12828
Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped,If Other than Above
a Address
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/13/2021 Registrar of Vital Statistics WgbertAndrew Curtis(Efectronica((y Signed)
(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:
Z Date of Disposition SI►y i` l Place of Disposition u L_ ,o�
(address)
2
W
Er N (section) itlot number) (grave number)
GName of Sexton or Person in Charge of Premis °` �'�
(Plea print) /''
W errO
Signature Title L �`�" �
DOH-1555(o7/18)p 1 of 2
Pp
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#