Dean Jr, Robert NEW YORK STATE DEPARTMENT OF HEALTH1 6 4 )t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Lee Dean Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2017 65 War or Dates
� Place of Death Hospital, Institution or
j j City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑Natural Cause � Accident Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W` Medical Certifier Name Title
t
Darci Gaiotti-Grubbs, M.D Dr.
et
Address
102 Park Street Glens Falls, NY 12801
a. Death Certificate Filed District Number Register Number
City, Town or Village
E❑Burial Date Cemetery or Crematory
January 24, 2017 Pine View Crematorium,,
nomm )ElEtb � Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z-riRemoval and/or Held
and/or Address
Hold
01 Date Point of
ate, El Transportation Shipment
M. by Common Destination
Carrier
-. Date Cemetery Address
Disinterment
, IllReinterment Date Cemetery Address
eeti Permit Issued to Registration Number
A- Name of Funeral Home Carleton Funeral Home, Inc. 00281
el Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
A Name of Funeral Firm Making Disposition or to Whom
HRemains are Shipped, If Other than Above
2 Address
it
r',!:i Permission.is hereby granted to dispose of the human remains described above as indicated.
Date Issued J 12. y 126 i7Registrar of Vital Statistics :) U
(signature
District Number 5 t Place �QN\.s c\' S,P
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
21
a, Date of Disposition 01/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804
Il :i
(address)
LIE
(section) (lot number) ( (grave number)
04 Name of Sexton or Person in Charge of remises 1��` �11�a l
ZE (please print)
Signature a V Title Crmftlig-
(over)
DOH-1555 (02/2004)