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Lackey, Richard Arnold '117 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Arnold Lackey Male Date of Death Age If Veteran of U.S.Armed Forces, 06/04/2021 66 Years War or Dates 1973-1975 Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 208 Corinth Road,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause ❑Accident El Homicide ❑Suicide El Undetermined Pending Circumstances Investigation W Medical Certifier Name Title CI Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 119 ElBurial Date Cemetery,Crematory or Facility Name 06/07/2021 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 6 Removal Date Place Removed and/or and/or Held F- Hold Address 0 d Date Point of (I) j Transportation p by Common Shipment Carrier Destination EiDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above g Address 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 Carol'ne7-(iflegarie Bar6er(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1 r ~ dew Z Date of Disposition 4(`!I'if Place of Disposition •Rtt 2 (address) W number) (grave number) CC (section) dlift �,•• ...snot Name of Sexton or Person in Charge of emises - �ti (ple a print) W Signature Title **VW DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Q , 4 Receipt Human remains of # delivered on , 20 1 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ' '