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Richards Sr., Mitchell L
0 N , r 17Z NEW YORK STATE DEPARTMENT OF HEALTH .x Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mitchell L Richards Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 06/03/2021 50 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Lake Luzeme Town Street Address 151 East River Avenue,Lake Luzerne Town,New York 12804 p Manner of Death ©Natural Cause Accident Homicide El Suicide 0Undetermined El Pending IlU C.) Circumstances Investigation W Medical Certifier Name Title 0 Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 9 ElBurial Date Cemetery,Crematory or Facility Name 06/07/2021 Pineview Crematory ElEntombment Address EiCremation Queensbury Town,New York 0 Donation 60 Removal Date Place Removed - and/or and/or Held H- Hold Address 0..CO O Date Point of Cl) ❑Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address Date Cemetery Address ElReinterment Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 1" Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/07/2021 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— +f WDate of Disposition (p/�I'li Place of Disposition +1(iJ -- or,....,_2 address) W it (section) of number) (grave number) • Name of Sexton or Person in Charge of Pre ' es �`' Al Q please/ int) Z Crr'n v►6 W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) U 1 4 8 . 44 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#