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Foster,Richard Shortell tur. Icio N EW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Shortell Foster Male Date of Death Age If Veteran of U.S.Armed Forces, 02/24/2023 73 Years War or Dates 1967-1970 Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W Manner of Death Undetermined Pending � �Natural Cause Accident �Homicide Suicide W Circumstances Investigation W Medical Certifier Name Title Philip Gara MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 24 Burial Date Cemetery,Crematory or Facility Name 02/27/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation OZ❑Removal Date Place Removed and/or and/or Held N Hold Address 0 d Date Point of V)❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above a Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/27/2023 Registrar of Vital Statistics Aimee G Mahoney(ECectronicaffy Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF— Z Date of Disposition 2 ft- 173. Place of Disposition �L (address) W CC N (section) (lot nuniberrl1.„44 (grave number) G Name of Sexton or Person in Charge remises Yp/ease print) W Signature Title (0)9Pif1--te DOH-1555(07/18)p 1 of 2 f_ 7 . 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# ''