Martin, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert J. Martin Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/11/2018 88 War or Dates 1948- 1952
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 151 Montray Road
pManner of Death C Natural Cause Accident n Homicide Suicide []Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Patricia Auer,NP _
Address
161 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury S6S1
®Burial Date Cemetery or Crematory
Entombment August 15,2018 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
co
O Date Point of
u) n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
(�Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
cc
ILI
Permission is hereby granted to dispose of the human re escri e o ind ted.
Date Issued (8-14-- a Registrar of Vital Statistics
(signatu
District Number £(.,S1 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
im Date of Disposition 8/1 5/201 8Place of Disposition Pine View Cemetery Oueensbury
(address)
U) Mohican 48—D 1
Ce (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie Goedert
Z / (please print)
Signature A,- (/ r2 - Title Cemetery Superintendent
(over)
DOH-1555(02/2004)