Daniels, Rickey L ry 7 it 102.
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rickey L.Daniels Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/28/2023 61 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑X Natural Cause IllAccident ❑Homicide Suicide Undetermined ri Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 57
Burial Date Cemetery,Crematory or Facility Name
01/30/2023 Pine View crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
g 0 Removal Date Place Removed
- and/or and/or Held
H- Hold Address
N
0
d Date Point of
CO Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
El
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1.— Remains are Shipped,If Other than Above
2 Address
IIr
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/30/2023 Registrar of Vital Statistics !Megan Wolin(ECectronica(ry 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:
ZZ
Date of Disposition ('}13i i Z3 Place of Disposition A_ / 1
LLI
2 (address)
W •
NCC (section) (lot numb (grave number)
S Name of Sexton or Person Charge of Premises r
(please print/
W Signature 7.0 Title rrZwi1 t aC
DOH-1555(07/AS)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#