Robarge, Harold NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit P It
Name First Middle "u Last Sex
Harold M. Robarge Male
Date of Death Age If Veteran of U.S.Armed Forces,
January 23, 2006 55 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address 17 Blinn Street
Manner of Death ❑Natural Cause ❑Accident ❑Homicide X❑Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
W Dr. Max Crossman MD
Address
79 North Street, Granville, NY 12832
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall <— a
❑Burial Date Cemetery or Crematory
1/27/06 Pineview Crematorium
❑Entombment Address
▪ Q Cremation Queensbury, NY 12804
Date Place Removed
4 ❑Removal and/or Held
- and/or Address
Hold
Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
a ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00931
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
aAddress
Permission is hereby granted to dispose of the hums remains described above as indicated.
Date Issued \ of to—Q(,2 Registrar of Vital Statistics _, QQ(�CSY�
(signature)
District Number 51a�d Place Whitehall,New rk
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition {'VI_ 0(, Place of Disposition Pineview Crematorium
W (address)
0
0 (section) (lot numb r) (grave number)
r,
Z Name of Sexton or Person in Charge of Premises G-14�Z� �.9t a fib N
(please print)
Signature 0� � �� Title C, r�l /4+G
412
(over)
DOH-1555 (02/2004)