Wood, Robert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Glenn Wood Male
E: Date of Death Age If Veteran of U.S.Armed Forces,
02/19/2018 70 Years War or Dates 1966-70
Place of Death Hospital, Institution or
City, Town or Village Ballston Spa Village Street Address Saratoga Center for Rehab and Skilled Nursing
Manner of Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tit
tu Medical Certifier Name Title
Vina Patel MD
Address
149 Ballston Ave,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number -
City, Town or Village Ballston Spa Village 4520 11
,, ❑Burial Date Cemetery or Crematory
02/21/2018 Pine View Crematory
❑Entombment Address
ens
Cremation Queensbury Town, New York
° Date Place Removed
- r—i❑Removal and/or Held
and/or
Address
t1 Hold
Q Date Point of
S❑Transportation _ Shipment
`'` by Common Destination
Carrier
17,7
`. Date Cemetery Address
❑Disinterment
ElReinterment Date Cemetery Address
` Permit Issued to Registration Number
',. Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
-- 136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is herebygranted to dispose of the human remains described above as indicated.
P e .
1
Date Issued 02/21/2018 Registrar of Vital Statistics Teri Lee()Connor(ECectronicalTySigned)
(signature)
District Number 4520 Place Ballston Spa Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1
W Date of Disposition 2122lif Place of Disposition f J,/
a (address)
ta
41
re (section) /l (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises [ �r� .-,10'
f (please print)
Signature Title /tt/6mHmg_
(over)
DOH-1555 (02/2004)