Randall, Richard Victor q11
NEW YORK STATE DEPARTMENT OF H EALTH N�,. Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Victor Randall Male
Date of Death Age x If Veteran of U.S.Armed Forces,
11/29/2022 82 Years War or Dates 1960-62
F., Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
V
Circumstances Investigation
W Medical Certifier Name Title
G Margarita Defedericis MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 600
Burial Date Cemetery,Crematory or Facility Name
12/03/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
(/)❑Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
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
i— Remains are Shipped,If Other than Above
N Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/02/2022 Registrar of Vital Statistics Megan Nolin(Electronically 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:
IF- '�
Z Date of Disposition /Z-3-zez L_ Place of Disposition ! r iJe V i t- repi, r
ILI
(address)
Ill number)
CC (section) (lot numbe) (grave
0 ( A KI41pdT filth
0 Name of Sexton or Person in Charge of emise
(please print)
Z - 1(-zy
uJ Signature i ,�� Title �{' �
DOH-1555(07/18)p 1 of 2 �/`
Public Health Law Sec. 4145(2b)
Receipt
•
Human remains of delivered on , 20
I.) •'` y .
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License# ti/