McDermott, RobertNEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
LF) Burial - Transit Permit
Name First Middle Last
Sex
I
Robert Emmett McDermott
Male
Date of Death
Age
If Veteran of U.S. Armed Forces,
09/29/2019
83 Years
War or Dates 1955-1975
Place of Death
Hospital, Institution or
City, Town or Village Queensbury Town
Street Address 35 Waverly Place, Queensbury Town, New York 12804
W
p
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ❑ Pending
W
Circumstances Investigation
V
W
Medical Certifier Name Title
Glen Anderson PA
Address
9 Carey Road, Queensbury Town, New York 12804
Death Certificate Filed
District Number
Register Number
City, Town or Village Queensbury
5657
142
Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/01/2019 Pine View Cemetery
Address
RCremation
Queensbury Town, New York
Donation
Z
Removal
Date
Place Removed
and/or Held
F--
and/or
Hold Address
N
O
a
Date Point of
to
Q
❑Transportation Shipment
by Common
Carrier
Destination
Disinterment
Date
Cemetery Address
Reinterment
Date
Cemetery Address
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
W
W
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/30/2019 Registrar of Vital Statistics Carolsrre7fr�igarde (Barder(ElectromcaiTyS#,zeq)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�•w
Date of Disposition (T Place of Disposition ,r\.•
{Z
(address)
W
(section) fot number/ (grave number)
Name of Sexton or Person in Charge of Premises /ht
(pf a print)
Z
W
Signature Title
DO H-1555 (07/18) p 1 of 2
Public Health Law Sec. 4145(2b) 012573
Receipt
Human remains of�delivered on 20/2
Pine View Cemetery R� senting the funeral home named on burial permit
Official Funeral Directors Reg. or License # 107LJ�