Anderson, Richard Mark ifioc
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Mark Anderson Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/02/2021 66 Years War or Dates 1983-1990
�... Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
`Q Manner of Death El Natural Cause Accident Ei Homicide Ei Suicide 0 Undetermined El Pending
✓ Circumstances Investigation
ntl Medical Certifier Name Title
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 231
ElBurial Date Cemetery,Crematory or Facility Name
06/04/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
0 Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
O
O. Date Point of
fA❑Transportation
Q by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
F.. Remains are Shipped,If Other than Above
g Address
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/03/2021 Registrar of Vital Statistics Xlp&ert./?ndvrw Curtis(Ekctronicadj Srgned)
(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:
IH
Z Date of Disposition _,zoe Place of Disposition B � ���. e ry,4
2 (address)
W
N
Q (section) (lot number) (grave
/grave number/
8 Name of Sexton or Person in Charge Premis lAYY1 o:a E 1A
(please print)
W Signature ' k Title Q 19
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01487,1.2.
Receipt
Human remains of s delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#