O'Dell, Ricky J 4- i ' � 4713
NEW YORK STATE DEPARTMENT OF HEALTH ,: Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ricky J.O'Del Male
Date of Death Age If Veteran of US.Armed Forces,
09/05/2022 59 Years War or Dates
i_ Place of Death ''.4 Hospital.Institution or
Z City,Town or Village Queensbury Town Street Address 862 Ridge Road B,Queensbury Town,New York 12804
W ❑Manner of Death El Natural Cause DAccident Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
G Christopher Mason DO
" rt; Address
100 Park 4t,,,,4le iFals,'New York 12801
Death Certiccate Filed Town Of Qrteensbury District Number Register Number
a�e
0 5657 127
Burial Date Cemetery,Crematory or Facility Name
09/082022 Pine View Crematory
Entombment Address
MCremation tensburY Tk#wrr,New York
Donation
--lRemoval Date Place Removed
and/or and/or Held
u Hold Address
tsl Date Point of
TreChsportationommon p Shipment
by
Carrier Destination
C
Date Cemetery Address
❑Disinterment
Date Cemetery Address
OReinterment
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
CC
w
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/07/2022 Registrar of Vital Statistics Carane.?t'rrlgartfs lia✓ber( 'learon a?3'
(signature
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— � /I
Z Date of Disposition 9/9 I ZZ Place of Disposition 't .J LA—
IIJ
a (address/
W
CACC (section) (lot number/ S (gran,number)
2 Name of Sexton or Person in Charge of ises A Awl IT
Z 4eL
ase print)
W L// fr mfiTo�(
Signature Title
DOH-1555(07/18)p 1 of?
1
1 ,- a
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of &livered on , 20 A
Pine View Cemetery Representing the funeral home named on bural permit
Official Funeral Directors Reg. or License#