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Grant, Richard 7 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Grant Male Date of Death Age If Veteran of U.S.Armed Forces, 01/06/2022 53 Years War or Dates f.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 11 Chelsea Way,Glens Falls,New York 12801 ILI 0 Manner of Death ©Natural Cause ❑Accident ❑Homicide 1=1 Suicide ❑Undetermined ❑Pending 11.1 LI Circumstances Investigation W Medical Certifier Name Title a Kenneth France MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 16 ❑Burial IDate Cemetery,Crematory or Facility Name I 01/10/2022 Pine View Crematory QEntombment Address ElCremation Queensbury Town,New York ▪Donation Z Removal Date Place Removed and/or and/or Held F— Hold Address N 0 CL Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/10/2022 Registrar of Vital Statistics Megan No fin(ECectronically 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: ZW Date of Disposition i/(j 1ZZ. Place of Disposition �,�AUL-- 40(1,•-- 2 (address) W Cl)CC (section) (lot number)l (grave number) - UL. G Name of Sexton or Person in Charge of Premis r Z (pi e print) W Signature / r g Title C ►ik'(De., DOH-1555(07/18)p 1 of 2 5 5 2 Public Health Law Sec. 4145(2b) k" ' 1 Receipt Human remains of delivered on , 20 • 1 1 1 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License#