McSpadden, Richard Gibson Jr. .,....c.LICif...)
tt AO
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Gibson McSpadden Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/01/2023 63 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village North Elba Town Street Address 27 Airport Lane,North Elba Town, New York 12946
p Manner of Death 0 Natural Cause Accident f n Homicide Suicide []Undetermined ❑Pending
U ILI1 'Circumstances Investigation
W Medical Certifier Name Title
C3 Jay Heald Coroner
Address
37 Hillman Lane,Lewis Town Essex,New York 12950
Death Certificate Filed Town Of North Elba District Number Register Number
City,Town or Village 1560 82
RBurial Date Cemetery,Crematory or Facility Name
10/03/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
4. Date Point of
V)❑Transportation
p by Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/03/2023 Registrar of Vital Statistics Laurie Curtir Dua7ey(Electronica�Signed)
(signature)
District Number 1560 Place Town Of North Elba
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZW Date of Disposition 1011173 Place of Disposition f I N fvi F--d i Fi�irv►A "(ORS-..,
2 (address)
W
NCC (section) (lot number) (grave number)
ci Name of Sexton or Person in Ch ge of Premises /4 L— -'I"k
z I Zr ......-• (please print)
W Signature Title � ��
DOH-1555(07/18)p 1 of 2
1`7 . 'CI
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#