Locke, Robert J. _ 13
NEW YORKSTATE DEPARTMENT OF HEALTH ter' Burial - Transit Permit
Bureau of VitAecords
Name - First Middle Last Sex
Robert J.Locke Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/15/2019 69 War or Dates 1969-1973
F Place of Death Hospital,Institution or
WCity,Town or Village Hadley Street Address 3951 North Shore Rd.
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending LLJ
V Circumstances Investigation
W Medical Certifier Name Title
93 George Siniapkin MD
Address
Palmer Ave.,Corinth, NY 12822
Death Certificate Filed District Number Register Number
City,Town or Village
Burial Date Cemetery,Crematory or Facility Name
Pine View Crematory
Entombment Address
®Cremation
Donation Queensbury, NY
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Date Point of
N ā¯‘Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St., Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Otherthan Above
Address
W
0- Permission is hereby granted to dispose of the human remains described above as indicat .
Date Issued 11/18/2019 Registrar of Vital Statistics y
(signature)
District Number 5 Place Town of Hadley
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 11--1 j-7 Place of Disposition R?h 0-V, C,/' M G
lu (add ess)
W
N (section) (tot number) (grave number)
IX
GName of Sexton or Person' ge o Premises
Z (please print)
W Signature Title a2k/s-
DOH-1555(07/18)p of 2
013088
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20.E
Pine View Cemetery h Representing the funerat home named on burial permit
Official Funeral Directors Reg.or License# '