Stark, Robin IN Ho
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robin A. Stark Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 12,2018 59 War or Dates
Place of Death Hospital, Institution or
;Z: City, Town or Village Glens Falls Street Address 14 Madison Street
Az, Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
a: Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ). 2 L/
❑Burial Date Cemetery or Crematory
❑Entombment April 16,2018 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
l i Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
.. Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1. Remains are Shipped, If Other than Above
2: Address
it
Y74" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued w/ l 6/ ZOI'' Registrar of Vital Statistics U7CAA.y1----e L A.,
ignature)
District Number 5601 Place Glens Falls)Al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y I l 't'3 Place of Disposition ?,.tlJ.,,,, e$,c1or4,-..,
W (address)
cn
re (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises 4.,, �- .54.—t
Z , (ease print)
Signature k- Title it 'lj ili?--.
(over)
DOH-1555 (02/2004)