Sousie, Ricky William L.C. l
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
. Name First Middle Last Sex
Ricky William Sousie Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/18/2022 62 Years War or Dates
ZZ Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
UI
Q Manner of Death nNaturalCause []Accident Homicide Suicide Undetermined ❑Pending
0 1 ' Circumstances Investigation
GW Medical Certifier Name Title
Michael Adams MD
Address
1448 Route 9,Fort Edward Town,New York 12828
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 274
❑Burial Date Cemetery,Crematory or Facility Name
Ei05/20/2022 Pine View CrematoryEntombment Address
Cremation Queensbury Town,New York
Donation
0 ORemoval Date Place Removed
and/or and/or Held
F_ Hold Address
V)
0
CL Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
E 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
F Remains are Shipped,If Other than Above
2 Address
L
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/19/2022 Registrar of Vital Statistics 9v1egan Notin(cECectronically Signed)
(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:
Z Date of Disposition 5-f 7,0 Ivt Place of Disposition /i�.t ti..— 4.....__
UJ
'`S (address)
W
CO
CC (section) dot number) S4.4t(Ifrave
number)
0 Name of Sexton or Person in Charg Premises
Z (please pl t) /'
qJ Signature � Title L 71�
DOH-1555(07/18)p 1 of 2
r
Public Health Law Sec. 4145(2b)
Receipt
uman remains of delivered on , 20
etery Representing the funeral home named on burial permit
Funeral Directors Reg.or License#