Archambault, Robert NEW YeiFiK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert W. Archambault Male
Date of Death Age If Veteran of U.S. Armed Forces, '
';;;; 05/77/2019 70 years War or Dates /196?2 —/76 /
.1 Place of Death Hospital, Institution or
Z City, Tow it Street Address
ttl AAA XX Glens Falls Glens Falls Hospital
W Manner of Death❑Natural Cause El Accident ❑Homicide El Suicide ❑Undetermined 1-1 Pending
Circumstances Investigation
uj Medical Certifier Name Title
44. John P. Stauterburg M D
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Towrj ftrXJillftlXX Glens Falls • 5501 243
Niii El EOM Date Cemetery or Crematory
['Entombment Pine View Cemetery
Address
❑Cfernation--" Queens-bury. NY 12804
Date Place Removed
Z El Removal and/or Held
2 and/or
- Address
'
Hold
Date Point of
Transportation Shipment
el by Common Destination
iiiiiii Carrier
❑Disinterment Date Cemetery Address
iig
❑Reinterment Date Cemetery Address
iliiiiNi Permit Issued to • - Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
i . Remains are Shipped, If Other than Above
Address
t
11.1 .
P." Permission is hereby granted to dispose of the human remains described above as indicated.
illi Date Issued - 05/29/2012 Registrar of Vital Statistics y1 y t U -Y
(signature)
District Number 5601 Place Glens Falls y NI 4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f*i2
til Date of Disposition 5/31 /1 2 Place of Disposition Pine View Cemetery
(address)
ta Unadilla Ext. 39 B 3
CC (section) (lot number) (grave number)
CA Name of Sexton or Pers , ' Charge of Premises Michael Genier
2 (please print)
iii SignatureO Title Superintendent
(over)
DOH-1555 (02/2004)