Shufelt, Robert r g.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
„, Name First Middle Last Sex
Robert W.Shufelt Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/22/2018 66 Years War or Dates
I- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
W; Circumstances Investigation
iti Medical Certifier Name Title
a Gwendolyn Morris-Dickinson PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 451
❑Burial Date Cemetery or Crematory
09/28/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
.� and/or Address
F. Hold
(J3
0 Date Point of
ai❑TransportationCO Shipment
Q by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
�.� Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
E
W
ad Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/24/2018 Registrar of Vital Statistics &i6ertA Curtis(cE(ectronicalTy Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /D/1 fit Place of Disposition ?At V—, �,
2 (address)
w
CO
W (section) (lot nu ber) (grave number)
pName of Sexton or Person in Charge o Premises 1� L S tvoirl
Z (please prim)
Lli r^' Title '1 W.
Signature s
(over)
DOH-1555 (02/2004)