Lutz, Richard Michael .*..). 11-
NEW YORK STATE DEPARTMENT OF HEALTH — Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Michael Lutz Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/22/2022 45 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death []Natural Cause []Accident 0 Homicide []Suicide Undetermined ❑Pending
UI I Circumstances Investigation
Q Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 283
RBurial Date Cemetery,Crematory or Facility Name
05/24/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
IIIDonation
0❑Removal Date Place Removed
and/or and/or Held
E— Hold Address
N
0
a Date Point of
U)OTransportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
C Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
5 Address
lr
LU
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/23/2022 Registrar of Vital Statistics Megan.Norin(ECectronicafIySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
!—
WDate of Disposition 3�ZS�it Place of Disposition R�U`, ,.�,�
2 (address)
LU
U) (section) 1(lot number) Sm., (grave number)
0 Name of Sexton or Person in Charge of Premises
r�J ��
Z /plea print)
LU Signature IP .(w Title 4F it
DOH-1555(07/18)p 1 of 2
t..tm ' i
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#