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Sargent, Robert Richard NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Richard Sargent Date of Death Age If Veteran of U.S.Armed Forces, 01/24/2020 76 Years Waror Dates 1962-1962 F Place of Death Hospital,Institution or W City,Town or Village Hartford Town Street Address 502 Blood Street,Hartford Town, New York 12832 p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined Pending UCircumstances Investigation QMedical Certifier Name Title Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 2 Burial Date Cemetery,Crematory or Facility Name 01/28/2020 Pine View Crematorium Entombment Address Cremation Queensbury Town,New York ❑Donation Z Date Place Removed a ❑Removal P and/or and/or Held N Hold Address O a- Date Point of N Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom F. Remains are Shipped,If Other than Above Address W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/28/2020 Registrar of Vital Statistics Denise(Petteys(ElectronicaCCySigned) /signature) District Number 5759 Place Hartford, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H 2 Date of Disposition t0 Place of Disposition W t `„i 2 (address/ W Ncc /section) lot number/ (grave number/ aName of Sexton or Person in Charge of Premiss hw 4r Z /ple a print) Signature6 Title ""�1T DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013287 Receipt Human remains of i �T .-� pdr:s . , �' delivered on , 20 1 j Pine View Cemetery Representing the funeral home named on ba*al permit Official Funeral Directors Reg.or License#