Varney, Robert left
—53
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:, Name First Middle Last Sex
_" Robert Kenneth Varney Male
• Date of Death Age If Veteran of U.S.Armed Forces,
; 09/08/2018 75 Years War or Dates 1960-1964
_ Place of Death Hospital, Institution or
riii City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death 0 Natural Cause 0 Accident Ei Homicide 0 Suicide EiUndetermined 0 Pending
1.1 Circumstances Investigation
• Medical Certifier Name Title
Thomas Kandora MD
XI
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 50
• D ieurial Date Cemetery or Crematory
09/10/2018 Pine View Crematory
• DEntombment Address
®Cremation Queensbury Town, New York
et
Date Place Removed
• Removal and/or Held
and/or Address
Hold
Date Point of
°� Transportation Shipment
by Common Destination
Carrier
f Date Cemetery Address
• Disinterment
t. Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
0 82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
jar Date Issued 09/10/2018 Registrar of Vital Statistics Aimee 9itakoney OctronicaCCy Signed)
(signature)
District Number 5755 Place Fort Edward, New York
0 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I)MIS Place of Disposition fM L, 424.tor*--
(address)
(section) fiat number) (grave number)
Name of Sexton or Person in Charge of Premises lAfri }Pr 3 akA4U-
(p/e eprint)
SignatureWI
Title 14m9Pit
(over)
DOH-1555 (02/2004)