Coughlin, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section " Burial - Transit Permit
Name First Middle Last Sex
Robert J. Coughlin Male
I' Date of Death Age If Veteran of U.S. Armed Forces,
f
X:?:.:0 June 29, 2017 78 War or Dates NA
Place of Death Hospital, Institution or
I. City, Town or Village Town of Queensbury,NY . Street Address 144 Wildwood Place, Queensbury, NY
. Manner of Death X Natural Cause Accident 0 Homicide n Suicide Undetermined n Pending
Circumstances Investigation
+ Medical Certifier Name Title
Charles Yun,MD
f Address
r` 102 Park Street,Glens Falls,NY 12801
0 Death Certificate Filed District Number Register Number
City, Town or Village Queensbury, NY .SL951 ?P—
❑Burial Date Cemetery or Crematory
July 3, 2017 Pine View Crematorium
❑Entombment Address
L1 Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
Q Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
pPermit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
V, Address
53 Quaker Road, Queensbury, NY 12804
rr f Name of Funeral Firm Making Disposition or to Whom
f''} Remains are Shipped, If Other than Above
Address
.} Permission is hereby granted to dispose of the human re d s i e ove i is d.
{ Date Issued L-3D-'1 Registrar of Vital Statistics i7 �
eE�A,,
f r
,+f,:. ,.� (signature)
r''% District Number cips� Place 4„,,,,, �l 2-/l 5
H I certify that the remains of the decedent identified ab ve were disposed of in acco nc with this permit on:
Z � �•
ui Date of Disposition 7 13)tj Place of Disposition gs4 L" fore,—
(address)
W
U)
0 (section) (lot number) (grave number)
Q, Name of Sexton or Person in Charge of Premises gr (er- 3-v,./tf
Z (pl ase print)
W Signature Title tiee mnT L
(over)
DOH-1555(02/2004)