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Stark, Ricky Martin Jr. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Rycky Martin Stark Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 08/16/2023 14 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Glens Falls Street Address Glens Falls Hospital ILI p Manner of Death Natural Cause Accident Homicide nSuicide FlUndetermined Pending fili Circumstances Investigation EMedical Certifier Name Title Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village , 5601 387 Burial Date Cemetery,Crematory or Facility Name 08/19/2023 Pineview Crematorium Entombment — Address ©Cremation Queensbury Town,New York EiDonation fl Removal Date Place Removed and/or and/or Held Hold Address CO Transportation Date Point of ZS by Common Shipment Carrier Destination Disinterment Ei Date Cemetery Address CReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom }. Remains are Shipped,If Other than Above Address itr ttt EX Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/18/2023 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: Date of Disposition $f 9.ZOZj Place of Disposition r l„/4 0 .44) (r eirpt, r IliZ (address) ili (section) (lot num er) (grave number) Name of Sexton or Person in Charge of Premises 4 rh16i✓b Wa0' Zr (please print w Signature Title Icy,E"ivr DOH-1555(07/18)p 1 of 2 0 7 Public Health Law Sec. 4145(2b) ' Receipt „ r Human remains of -1 delivered on / ' , 20 ( ' Pine View Cemetery Representing the funeral home named orkl)upeal prmit Official Funeral Directors Reg. or License#