Simonson, Richard Mc Kay e. 7,,- -, ,,,
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard McKay Simonson Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/30/2022 82 Years War or Dates 1958-1960
i_ Place of Death Hospital,Institution or
Z City,Town or Village Fort Ann Town Street Address 1093 Copeland Pond Road,Fort Ann Town,New York 12827
SMannerof Death El Natural Cause DAccident El Homicide OSuicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Alexandra Aarons MD
Address
3 Irongate Center,Glens Falls,New York 12801
DeEath Certificate Filed Town of Fort Ann District Number Register Number
Cit ,Town orVill a 5754 20
Burial Date Cemetery,Crematory or Facility Name
10/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
F and/or and/or Held
W Hold Address
O
A. Date Point of
(I) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
ElReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Other than Above
2 Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/03/2022 Registrar of Vital Statistics .7ennffsr'Jac' n(EfsetmnicoQySrgtr4
/signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Ri( (n Place of Disposition - , )`,,_ 74- .
X (address)
W
CO
CC (section) 3r, (lot number) /grehr number)
g Name of Sexton or Person in Cha of PreY__
is - '�^t�t
Z /p< ase print/
W I Signature 7X Title AZEt444 L
DOH 1555(o7/18)p t of 2
d
1 Q
Public Health Law Sec. 4145(2b)
Receipt
Human remains of r' si delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#