Wescott, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Taylor Wescott Male
Date of Death Age If Veteran of U.S. Armed Forces,
Place o feat
11/ld/201h2 71 years War or Dates 1962 1970
Hospital, Institution or
City, To ��V Street Address
0 Manner�Or eat X Clcns Fails_ ❑ ❑ Glens Fr,1alu Hdeteimi ❑
Natural Cause u Accident Homicide Suicide L!1 undetermined Pending
C? Circumstances Investigation
W Medical Certifier Name Title
a
Add essi A Gaiotti grubbs M D
102 Park St Glens Falls N Y 12801
Death Certificate Filed District Number Register Number
City, Tow Glens Falls 5601 507
[ [< ['purial ate Cemetery or Crematory
['Entombment Address 1/08/2012 Pine View Cemetery
- CrematiorT
Queensbury, NY 12804
Date Place Removed
K El Removal and/or Held
and/or Address
Hold
0 Date Point of
a`El Transportation Shipment
0 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
iiIiQ Reinterment Date Cemetery Address
lilii Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
« Address
111afayitte Street Oiieenshury, N Y 12804
Nii Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
l
` Permission is hereby granted to dispose of the human remains described above s in ted.
Date issued 1 ,/0512012 Registrar of Vital Statistics /4
(signature)
<; District Number Place
5601 Glens Fails
```'i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
#-
Z 11 /8/12 Pine View Cemetery
Date of Disposition Place of Disposition
(address)
0 Erie 43 B 1
CC (section) (lot number) (grave number)
Name of Sexton or Perso 4 harge of Premises Michael Genier
(please print)
144
Signature" �'^' Title - Superintendent
(over)
DOH-1555 (02/2004)