Haskins, Richard Dean : i
. 4 12
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Dean Haskins Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/05/2023 70 Years War or Dates Army
F.. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
W Ej Natural Cause Accident Homicide Suicide
V Circumstances Investigation
W Medical Certifier Name Title
0 Marvin Davidowitz 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 63
Burial Date Cemetery,Crematory or Facility Name
® 02/06/2023 Pine View Crematory
Entombment Address
ECremation Queensbury Town,New York
Donation
g0Removal Date Place Removed
and/or and/or Held
t- Hold Address
CO
0
0. Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
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
H 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 02/06/2023 Registrar of Vital Statistics MeganYoCIn(E/ctronica11:y 5gtted)
(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:
F ��
Z Date of Disposition 211 l Zg Place of Disposition ��...lI �./<<''—"
ILI (address)
111
CO (section) A (lot number) (grave number)
rl
0 Name of Sexton or Person in Charge of Premises �-' ^`
Z (�lease print)
W RZ
Signature /p-
Title � �
DOH-1555(07/18)p 1 of 2
x
Public Health Law Sec. 4145(2b)
Receipt
Human remains of i delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#