Ploss, Robert NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Ploss I Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/21/2020 69 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Wilton Town Street Address 25 New Britain Drive,Wilton Town,New York 12831
uj Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
John Mongan DO
Address
3 Care Lane,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Gansevoort 1 4569 110
Burial Date Cemetery,Crematory or Facility Name
03/24/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
F- Hold Address
FA
9L' 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 Compassionate Funeral Care Inc 100364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/24/2020 Registrar of Vital Statistics S-an Baklunn(EYectronrcaf Stgne4
(signature/
District Number 4569 Place Gansevoort, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition Place of Disposition t �
Uj (addres
W
N (section) (lot number) (grave number)
Name of Sexton or Person in Cha a of Premis 4W �
Z (p!ase print/
W Signature /` Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) s /4
Receipt
Human remains of !; -( . 1 delivered on '" ' , 20 L
f
Pink View Cemetery Representing the funeral home named on yurialj rknit
Official Funeral Directors Reg.or License#