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Birk, Robert NEW YORK STATE DEPARTMENT OF HEALTH _ �� Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert S. Birk Male Date of Death Age If Veteran of U.S. Armed Forces, 1 2/1 7/2 01 7 87 War or Dates no Place of Death Hospital, Institution or W City, Town or Village Lake Luzerne, Street Address 430 Old Stage Rd. p. Manner of Death© Natural Cause ❑Accident ElHomicide 0 Suicide 1-1 Undetermined El"—I Pending LIS CircumstancesInvestigation W Medical Certifier Name Title 0 Address Latham, NY Death Certificate Filed District Number Register Number City, Town or Village Lake Luzerne 5656 ❑Burial Date Cemetery or Crematory ❑Entombment 12/18/17 Pine View Crematory Address ®Cremation Queensbury, N Date Place Removed Z ❑Removal and/or Held o and/or Address Hold Date Point of N❑Transportation Shipment a by Common Destination Carrier El Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home, Inc. 00211 Address 24 Church St. , Lake Luzerne, NY 12846 Name of Funeral Firm Making Disposition or to Whom I- Remains are Shipped, If Other than Above Address cc in CI' Permission is hereby granted to dispose of the huma em ins d‘Avi'„ scribed bbbv as indicated. Date Issued a / Registrar of Vital Statistic L 7, ,S, /Z1c 6,Le (signature) District Number Place 4:<c /7_,(7 ,___e___ I certify that the remains of the decedent identified above M disposed of in accordance with this permit on: Z ') W Date of Disposition i2 f iy l h1 Place of Disposition f�,iLI—' .2 (address) W' CO c (section) / (lot number) (grave number) pName of Sexton or Person in Charge of Premi s t",-U c,„k- Z (please print) Ili Signature E- Title /rt mii1 -- (over) DOH-1555 (02/2004)