Down, Richard A # 353
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard A Down Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/23/2022 62 Years War or Dates
t,. Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 20 Marcelle Lane,Lake George Town,New York 12845
LU
p Manner of Death ❑X Natural Cause Accident Homicide Suicide FlUndetermined ElPending
W
0 Circumstances Investigation
G Medical Certifier Name Title
Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 9
^Burial Date Cemetery,Crematory or Facility Name
04/26/2022 Pine View Crematory
Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
W
A
CL Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
▪ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped,If Other than Above
2 Address
Q
W
0" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2022 Registrar of Vital Statistics Patricia R.Wc1 Jnney-Schuster(ECectronicalfySigned)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `
Z /
Z Date of Disposition 1I21li2 Place of Disposition hr .- --
UJ
2 (address)
W
NCC (section) ry (lot number) (grave number)
SName of Sexton or Person in Charge of Premises t�t� 4 it
Z (ple4se print)
W Signatures,7j , Title `PA41K
DOH-1555(o7/18)p 1 of 2
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#