Reardon, Robert William z k ) t (Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Perit
Bureau of Vital Records
Name First Middle Last Sex
Robert William Reardon Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/03/2020 52 Years War or Dates
II.- Place of Death Hospital,Institution or
Z City,Town or Vittage Moreau Town Street Address 5 Sand Hill Drive Apt A,Moreau Town,New York 12803
Lu
p Manner of Death ❑X Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 9
Burial Date Cemetery,Crematory or Facility Name
02/05/2020 Pine View Crematory
Entombment Address
x Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
F-
asHold Address
O
a Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/05/2020 Registrar of Vital Statistics GeeannMccaAe�-F&-tronicaffySigne4
(signature/
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
Z Date of Disposition 7 jb I Zo Place of Disposition
(address)
W
N (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
� � l lease print/
Z
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) J 1-3 31
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing"the funeral home named pn burial permit
Official Funeral Directors Reg.or License# i'