Stockwell Jr., Robert NEW YORK STATE DEPARTMENT OF HEALTH lli
Vital Records Section Burial - Transit Permit
gio Name) First Middle Last Sex
rRobert1Norman Stockwell Jr. Male
, Date of Death Age If Veteran of U.S. Armed Forces,
03/16/2 i18 63 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death frj Natural Cause ❑Accident [l Homicide 0 Suicide Q Undetermined ❑Pending
al
col Circumstances Investigation
pil Medical Certifier Name Title
IiiiLl
Sean Bain MD
Address
• 100 Park St,Glens Falls,New York 12801
4.1 Death certificate Filed District Nu ber Register Number
City, Town or Village Glens Falls 5601 136
littol
rim❑Kuria! Date Cemetery or Crematory
ga 03/19/2018 P[ne View Crematorium
❑Entombment Address
1Cremation Queensbury Town, New York
Date Place Removed
[J Removal and/or Held
ilN and/or Address
Hold',
iti Date Point of
u Transportation Shipment
by Common Destination
• Career
V,ElDisinterment Date Cemetery Address
Mil
• Reinterment Date Cemetery Address
Permit Issued to Registration Number
OA Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Lil Name of; Funeral Firm Making Disposition or to Whom
• Remain are Shipped, If Other than Above
• Address',gi ,
-
Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 03/19/2018 Registrar of Vital Statistics gto5ert A Curtis(Electronically Signal)
(srfgnature)
District Number 5601 Place Glens Fails, New York
ii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
kill Date of Disposition 3)Ze yl I Place of Disposition f 1.,-1 l
(address)
s (section) // (lot number) (grave number)
Name of Sexton or Person in Gharg of Premises t1,,t� -S..
"►ease pnn
411
SignatureTitle lk4Ij7
(over)
DOH-1555(02/2004)