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Gould, Richard Donald Sr. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Richard Donald Gould Sr Male Date of Death Age If Veteran of U.S.Armed Forces, 09/02/2023 86 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 'p Manner of Death ❑X Natural Cause Accident El Homicide El Suicide Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title CI Christopher Smith 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 418 Burial Date Cemetery,Crematory or Facility Name 09/05/2023 Pine View Crematorium _Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held Hold Address CO 0 a Date Point of (/) Transportation p by Common Shipment Carrier Destination 111 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 1— Remains are Shipped,If Other than Above Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/05/2023 Registrar of Vital Statistics Megan.Nolin(E(ectronical(ySigned) (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: Z Date of Disposition 111(763 Place of Disposition W 2 (address) W CC (section) (lot number) (grave number) 0 Name of Sexton or Person in Cha a of Premises !'^^ �— Z (p1se print) W Signature Title / t DOH-1555(07/18)p 1 of 2 r 11 79 - Public Health Law Sec. 4145(2b) Receipt Human remains of 1 delivered on - , 20 j 1 1; Pine View Cemetery Representing the funeral home named on bury permit Official - Funeral Directors Reg.or License#k