Howard, Richard A , ---10.... # /U13
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard A.Howard Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/10/2022 67 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Thurman Town Street Address 1827 Stony Creek Road Road,Thurman Town,New York 12810
UJ
p Manner of Death ❑-7 Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined L=I Pending
W V Circumstances Investigation
W Medical Certifier Name Title
O David Cunningham MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Athol 5659 4
IDBurial Date Cemetery,Crematory or Facility Name
02/14/2022 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
11 Donation
Z 0 Removal Date Place Removed
•
and/or and/or Held
H Hold Address
N
0
Date Point of
CD ❑Transportation Shipment
p by Common
Carrier Destination
ID 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
(— Remains are Shipped,If Other than Above
2 Address
CC
W
11.
,, Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/14/2022 Registrar of Vital Statistics Cynthia,x3'a (IE/ctronicaf Srgnerl9
(signature)
District Number 5659 Place Athol, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 'I /�
zR v l-Jt�
W Date of Disposition 2.�)5�Z'Z Place of Disposition ,n� i` d;�
(address)
W
CO (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premise /`' in AA,ti
Z (plea print)
W Signature Title
� MwiD
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#