Richards, Jeremy Yasgur r
NEW YORKSTATE DEPARTMENT OF HEALTH Bp
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jeremy Yasgur Richards Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/05/2022 47 Years War or Dates
t-. Place of Death Hospital,Institution or
WCity,Town or Village Ausable Town Street Address 1-87 North,Ausable Town,New York 12944
p Manner of Death 0 Natural Cause Accident Homicide ESuicide Undetermined ❑Pending
LU
C.) Circumstances Investigation
Q Medical Certifier Name Title
Chad Deans Coroner
Address
137 Margaret Street Ste 208,Plattsburgh,New York 12901
Death Certificate Filed Town Of Ausable District Number Register Number
City,Town or Village 0951 12
BurialR
Date Cemetery,Crematory or Facility Name
09/21/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation / • I
goRemoval Date Place Removed
and/or and/or Held
F Hold Address
CO
0
O. Date Point of
V)ElTransportation
p by Common Shipment
Carrier Destination
oDisinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
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
F- Remains are Shipped,If Other than Above
5 Address
CC
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/16/2022 Registrar of Vital Statistics Bonnie£7fopkins(ECectronicalTySigned)
(signature)
District Number 0951 Place Town Of Ausable
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition /?-Q-2oa! `ID,of Disposition � ,fie IA�� CT�jy� 14v
2 (address)
W
Cr (section) J (lot umber) (grave number)
aName of Sexton or Person in Charge o emi s /%►�Oei � Qb
Z i I(p/ease print)
IL Signature ` -- " /6 Title 0e�� T�'�
DOH-1555(07/18)p 1 of 2
1
Public Health Law Sec. 4145(2b)
1
1
1 Receipt
Human remains of • delivered on , 20
•
IPine View Cemetery '-Representing the funeral home*rained on burial permit
Official Funeral Directors Reg.or License#