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Bacon, Richard William ` 7ZD NEW YORKSTATE DEPARTMENT OF HEALTH LOF Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard William Bacon Male Date of Death Age If Veteran of U.S.Armed Forces, 09/08/2022 78 Years War )r Dates 1966-1968 F. Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 20 North Street, Hudson Falls Village, New York 12839 Manner of Death n nUndetermined Pending Ll Natural Cause nAccident I I Homicide nSuicide "Circumstances n W Circumstances Investigation W Medical Certifier Name Title CI Sean Campanie NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of Hudson Falls District Number Register Number City,Town or Village 5726 41 Burial Date Cemetery,Crematory or Facility Name 09/10/2022 Pine View Crematorium T Entombment Address IX'(Cremation Queensbury Town,New York CDonation ©nRemoval Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of t!)CTransportation by Common Shipment Carrier Destination Date Cemetery Address ri Disinterment Date Cemetery Address C Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street, P.O.Box 67, Hudson Falls, New York 12839 Name of Funeral Firm Making Disposition or to Whom F— Remains are Shipped,If Other than Above 2 Address Q W t'' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/09/2022 Registrar of Vital Statistics CvntIiaA Bardin(ElectronicairySigned) (signature) District Number 5726 Place Village Of Hudson Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 9 lit)lZ Place of Disposition t-V` (address) W CC (section) / _(lot number/ \ {� (grave number) Name of Sexton or Person in Char remises G' )(.1 -CJ r 1 ilease print) Z W Signature Title � � r"r DOH-1555(07/18)p 1 of 2 r ~ Public Health Law Sec. 4145(2b) , s 1 R ' Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home namecliou burial permit Official Funeral Directors Reg.or License#