Campbell, Robert r 1!
NEW YORK STATE DEPARTMENT OF HEALTH
#26�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Gar Campbell Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2017 47 War or Dates
Pla f eath �'� Hospital, Institution or
W Ci , Town r Village 1,\`F'- Street Address 208 Fifth Street
W Man Death❑Natural Cause ❑v�c dent ❑ Homicide E Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
G"1' Timothy Murphy,
Address
52 Haviland Ave Glens Falls, NY 12801
Death Certificate Filed District Number Regster Number
City, Town or Village S(-P ) `-f
❑Burial Date Cemetery or Crematory
March 30, 2017 Pine View Crematorium
El Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
E Hold
CODate Point of
0.'❑Transportation Shipment
O by Common Destination
a Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
a' Permission is hereby granted to dispose of the human re 'ns described above as indicated.
Date Issue& )c)-k--( / n Registrar of Vital Statistics Cj CS).__B .-i-_---_
— � - (signature
District Numberrj( '� Place - t )�_ qj, �r id u���
I certify that the remains of the decedent identified above were disposed of in accordance with this perm t on:
w Date of Disposition 03/30/2017 Place of Disposition Quaker Road Queensbury,NY 12804
;" (address)
W
00
re (section) -(lot number) ( (grave number)
0 Name of Sexton or Person in Charge of Premi s i 4 ris A .J kin i if
z
/� (p/ ase print)
W Signature G� Title (REA/110Q
(over)
DOH-1555 (02/2004)