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Pieper, Maxfield Adam NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Maxfield Adam Pieper Male Date of Death Age If Veteran of U.S.Armed Forces, 09/18/2021 33 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Glens Falls Street Address 18 Jefferson Avenue,Glens Falls, New York 12801 ip Manner of Death El Natural Cause 1=1 Accident Homicide El Suicide El Undetermined ©Pending Circumstances Investigation Medical Certifier Name Title Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 409 Burial Date Cemetery,Crematory or Facility Name 09/22/2021 Pineview Crematorium ElEntombment Address ElCremation Queensbury Town,New York EiDonation go Removal Date Place Removed and/or and/or Held Hold Address O 0- Date Point of CA L.j Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Radloff Funeral Home Inc 01425 Address 136 Warren St,Glens Falls,New York 12801 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address Q W f' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/22/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically 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: Date of Disposition 9 113171 Place of Disposition address) W (section) (lot number) 4^^" (grave number) SName of Sexton or Person in Charge of remises r-5" Z (plepse print) /' IU Signature ���,-.�— Title G QEMW TX DOH-1555(o7/t8)p t of 2 j "i Public Health Law Sec. 4145(2b) Receipt Human remains of x" delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# / {''