Lee, Richard I lob/
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard I Lee Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/11/2021 33 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 24 Big Boom Road 110,Queensbury Town,New York 12804
pManner of Death Lri Natural Cause ElAccident ❑Homicide ❑Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
Q
Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 238
Burial Date Cemetery,Crematory or Facility Name
12/14/2021 Pine View Crematory
Entombment Address
iCremation Queensbury Town,New York
ElDonation
Z Removal Date Place Removed
and/or and/or Held
t- Hold Address
U) ❑Transportation Date Point of
S by Common Shipment
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
F.. 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 12/13/2021 Registrar of Vital Statistics Caroline x(legarde Barber(E(ectronical(y Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Date of Disposition 12115 121 Place of Disposition s I VL,_
(address)
W
R
/section/ /ot number) (grave number)
8 Name of Sexton or Person in Charge of P ises r,' ^'tbt
Z � (pleas print) /
W Signature �/' rc_
Title ` A'w��
DOH-1555(07/18)p 1 of 2
—
f:.;. ,
Public Health Law Sec. 4145(2b)
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#