Robertson, Hammond b(10
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
a Burial - Transit Permit
Name First Middle Last Sex
Hammond Robertson ...r/Z Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 6,2006 81 War or Dates World War II
Place of Death Hospital, Institution or
ZCity, Town or Village City of Glens Falls Street Address Glens Falls Hospital
WG Manner of Death 0 Natural Cause El Accident El Homicide ❑ Suicide El Undetermined ❑ Pending
Circumstances Investigation
LU
0 Medical Certifier Name Title
LU Peter R. Gray Dr.
G
Address
90 South St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls _ 5601 60 /7
0 Burial Date Cemetery or Crematory
12/8/2006 Pine View Crematorium
❑ Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
Q and/or Address
H. Hold
dN Date Point of
❑ Transportation Shipment
0) by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan&Potter 01734
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
Address
re
d, Permission is hereby ranted to dispose of the human remains descri ed above as' icat
Date Issued 12,�8 O 6 Registrar of Vital Statistics ,/,/�' - �
(signature)
District Number 5601 Place 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 la/it/ob Place of Disposition 12in pv,e;,,, Cirivs At(.3r1�m
LU (address)
2
W
CC (section) 7,, CC(lot number) (grave number)
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0 Name of Sexton or Person in Charge of Premises Ch 5 ..Tc4 n e C4'
CI
Z (please print)
W Ael' g Signature (,L — Title �(e m el+o
DOH-1555 (02/2004) (over)