Lee Jr., Richard Eugene r
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Eugene Lee Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/14/2021 66 Years War or Dates Army
H
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause El Accident Homicide Suicide 0 Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 403
Burial Date Cemetery,Crematory or Facility Name
09/17/2021 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
(J) 11 Transportation Shipment
b by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/17/2021 Registrar of Vital Statistics 2WertAndrew Curtis(ECectronica1Cy Signed)
(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:
WDate of Disposition OOP") Place of Disposition )Q;n c, V;crW (-G+►'�ci �
2 III (address)
W
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Telr'�'y `S(,c7 fts
(please print)
W Signature Title C/cv+tOr
DOH-1555(o7/18)p 1 of 2
1 1 5 1
Public Health Law Sec. 4145(2b)
Receipt
• ,
Human remains of t7 ' delivered on , 20
•
•
Pine View Cemetery Representinblie funeral home named on burial permit
Official Funeral Directors Reg.or License#