Edwards, Richard Jesse A 11. 6s Z_
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Jesse Edwards Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/09/2021 65 Years War or Dates
F.. Place of Death Hospital,Institution or
W City,Town or Village Suffern Village Street Address Good Samaritan Hospital Of Suffern
`p Manner of Death Natural Cause Accident D Homicide El Suicide0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Chidinma Nwachukwu MD
Address
255 Lafayette Ave,Suffern Village,New York 10901
Death Certificate Filed District Number Register Number
City,Town or Village Suffern Village 4329 330
Burial Date Cemetery,Crematory or Facility Name
08/17/2021 Pine View Crematorium
Entombment Address
ElCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
F— Hold Address
0
n. Date Point of
C/) Li Transportation
by Common Shipment
Carrier Destination
Disinterment 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
Remains are Shipped,If Other than Above
5 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/11/2021 Registrar of Vital Statistics Lynne Bryant(E(ectronicaC(ySigned)
(signature)
District Number 4329 Place Suffern Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,� `�
W Date of Disposition 81 j4I 1l Place of Disposition r►�Kt LLC 6ce-.._
2 (address)
W
(/)
CC (section) ` (lot number).7504 (grave number)
Name of Sexton or Person in Char of Premises ' (/ kl�
o r�
Z lease print
tL Signature Title fryokK
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
IReceipt
Human remains of _ delivered on , 20
Pine View Cemetery Representing the funeral home named on(bial permit
Official Funeral Directors Reg.or License#