Rich, Julia M. tilj
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Julia M.Rich Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/14/2021 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
W a Natural Cause ❑Accident �Homicide Suicide
V Circumstances Investigation
W Medical Certifier Name Title
O Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 217
❑Burial Date Cemetery,Crematory or Facility Name
05/18/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
O
d 1-1 Date Point of
CA Li Transportation Shipment
p by Common
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
F Remains are Shipped,If Other than Above
2 Address
Ilr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/17/2021 Registrar of Vital Statistics Ro6ertf7n�irewCurtzi(' ctronica6Signe2
(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:
ZZ
Date of Disposition Si i°t I it Place of Disposition O�
2 (address)
W
CC (section) 1 Ant number) (grave number)
• Name of Sexton or Person in Charge of Pr ises r`( `-� itddt
Z > (plea*print)W /�Signature Title t I�.µW�vZ
g
DOH-1555(o7/i8)p 1 of 2
Public Health Law Sec. 4145(2b) 14 7�� w
Receipt
1
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#