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Mulholland, Richard James iC„ NEW YORK STATE DEPARTMENT OF HEALTH ' Burial - Transit Permit Bureau of Vital.Records Name First Middle Last Sex Richard James Mulholland Male Date of Death Age If Veteran of U.S.Armed Forces, 11/22/2023 61 Years War or Dates 1„,. Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing W Manner of Death n Undetermined Pending W Natural Cause Ei Accident I I Homicide Suicide C) Circumstances Investigation W Medical Certifier Name Title G John Quaresima MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 176 ▪Burial Date Cemetery,Crematory or Facility Name 11/27/2023 Pine View Crematory ❑Entombment Address ©Cremation Queensbury Town,New York ▪Donation _ O Removal Date Place Removed and/or and/or Held N Hold Address 0 Date Point of U)nTransportation by Common Shipment Carrier Destination Ei Disinterment Date Cemetery Address n Date Cemetery Address I I Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/24/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: l— � W Date of Disposition //Z, ZvZ3 Place of Disposition l i 'JO I/i(?,,) �--teli , K 2 (address) e1 W CC (section) clot lot�nfumber) (grave number) Name of Sexton or Person in Charge of P mis r4.y rw'✓ 142' ` / (please print) IJ1 Signature �c </� idG Title p-e- 4 DOH-1555(o7/i8)p t of 2 /'� a .. ..,, 7 b- . . 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#