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Ricahrds, Charles Otto # 7)g r NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Charles Otto Richards Male Date of Death Age If Veteran of U.S.Armed Forces, 09/18/2021 92 Years War or Dates Korea Place of Death Hospital,lhstitution or Z City,Town or Village Bolton Town Street Address 4825 Lake Shore Drive, Bolton Town, New York 12814 pManner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title O Bryan Smead MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 13 ❑Burial Date Cemetery,Crematory or Facility Name 09/22/2021 Pine View Crematory ElEntombment Address lCremation Queensbury Town,New York ❑Donation Z 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 Q. 1-1 Date Point of (I) ❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom H 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 09/21/2021 Registrar of Vital Statistics Jodi T'etteys(Electronically Signed) (signature) District Number 5650 Place Bolton Landing, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— C �� 7 Z Date of Disposition �in(1.tj Place of Disposition �f ,1,t Vi-- W (address) W NfE (section) (lot _jam (grave/grave number) SName of Sexton or Person in Charge of P mises t it its-VI— Z Z j (piea4'L print) W �iz�M it lait Signature .. � Title DOH-1555(o7/18)p 1 of 2 1 6 5 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# .1('`