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Richards, William G 4 L s 7 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William G Richards Male Date of Death Age If Veteran of U.S.Armed Forces, 08/19/2021 79 Years War or Dates 1961-64 Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 223 Antone Mountain Road,Hadley Town,New York 12822 Ili 0 Manner of Death ©Natural Cause El Accident El Homicide 0 Suicide 11 Undetermined 0 Pending IIJ Circumstances Investigation WMedical Certifier Name Title C Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 16 ElBurial Date Cemetery,Crematory or Facility Name 08/20/2021 Pineview Crematory Entombment Address O Cremation Queensbury Town,New York ▪Donation Z Removal Date Place Removed and/or and/or Held i Hold Address N 0 Date Point of U) ❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address ElDisinterment Date Cemetery Address 0 Reinterment 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 ,— Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/19/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit onn: Z Date of Disposition 1f(7O11,{ Place of Disposition OS— dd UJ (address) W N (section) A (lot number) (grave number) CC GName of Sexton or Person in Cha of Premises P� print) LLJ Signature Title itle CTA"11 DOH-1555(07/18)p 1 of 2 : 1 `P 0 6 Public Health Law Sec. 4145(2b) Receipt Human remains of `'' delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#