Tisinger, Robert 4 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
It Name First Middle Last Sex
r Male
3 Robert James Tisinger
Date of Death Age If Veteran of U.S. Armed Forces,
08/28/2018 82 Years War or Dates
<, Place of Death IHospital, Institution or
City, Town or Village Ballston Spa Village Street Address Saratoga Center for Rehab and Skilled Nursing
Manner of Death tj Natural Cause El Accident I:Homicide I:Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
0 Pamela Casey NP
Address
149 Ballston Ave,Ballston Spa Village,New York 12020
1J Death Certificate Filed District Number Register Number
4`P City, Town or Village Ballston Spa Village 4520 56
Date Cemeteryor CrematorIt- y
®Burial
09/01/2018 Pine View Cemetery
❑Entombment Address
['Cremation Queensbury, New York
,,,-Is.
Date Place Removed
ri❑Removal and/or Held
and/or Address
F Hold
_
4& Date Point of
wr❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
0 Date Cemetery Address
❑Reinterment
5 Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
IP 53 Quaker Rd,Queensbury,New York 12804
414
'- 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.
Date Issued 08/29/2018 Registrar of Vital Statistics Teri Lee OConnor(&ectronicalty Signed
(signature)
h District Number 4520 Place Ballston Spa Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 9/1 /201 8 Place of Disposition Pine View Cemetery Queensbury
3 (address)
Erie 53—E 1
VIA
M (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Connie Goedert
(please print)
ill � Cemetery Superintendent
Signatur l�l it�lQ Title
(over)
DOH-1555(02/2004)