Robinson, Ruth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'%/ Name First Middle Last Sex
Ruth
rf Marie Robinson Female
MI Date of Death Age If Veteran of U.S. Armed Forces,
.r March 21, 2015 78 War or Dates
Place of Death Hospital, Institution or
,.7 City, Town or Village Glens Falls Street Address Glens Falls Hospital•
Manner of Death 17.71
LAJ Natural Cause n Accident n Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
l Shahid Amed, MD
,,>: . —
Address
4. 100 Park Street,Glens Falls,NY 12801
�:.
Death Certificate Filed District Number Register Number, _
City, Town or Village Glens Falls,NY 5601 f
❑X Burial Date Cemetery or Crematory
May 9, 2015 West Glens Falls Cemetery
❑Entombment Address
❑Cremation Corinth Rd, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
H Hold
a
0 Date Point of
Nri Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,�,� Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
6
Address
' 53 Quaker Road, Queensbury, NY 12804
..p.l. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
/ Permission is hereby granted to dispose of the human remains described above as indicated.
it tl
Date Issued 514/ 1 j_5 Registrar of Vital Statistics (A)CAAiyv-e,W
,s
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 5/9/2 0 1 5 Place of Disposition West Glens Falls Cemetery, Quei nsbury
w (address)
co West Glens Falls Family Plot
W. (section) (lot numbe (grave number)
pName of Se on or Person in Charge of Premises Connie L. Goedert
Z C, (please print)
W
Signatur ce,c_ , Title Cemetery Superintendent
(over)
DOH-1555(02/2004)