Robbins, Bernice NEW YORK STATE DEPARTMEN HEALTH « . g'AO
.
Vital Records Section Burial - Transit Permit
- Name First Middle Last Sex
Bernice Packard Robbins Female
=.; Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2018 76 War or Dates
1 Place of Death Hospital, Institution or
6 City, Town or Village Granville Street Address 6 Potter Ave
Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
tIJ W Medical Certifier Name Title
Christopher Mason, Dr.
Address
CR Wood Cancer Center Glens Falls, NY 12801
. Death Certificate F. d District Number Register Number
City, Town o illage 1w7
`lam-. 5 7a5 13
., ❑Burial Dfe Cemetery or Crematory
October 24, 2018 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
_., Hold ZION EPISCOPAL CHURCH
CI Date Point of
t ❑Transportation Shipment
by Common Destination
Cif Carrier
E Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
: Permit Issued to Registration Number
m Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
il Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
" Address
LLI
�"` Permission is he eby granted to dispose of the human rem. '110 s de.. . :boy s indicated.
Date Issued Registrar of Vital Statistics i . �, -1101
(signature)
, District Number 3-7,75 Place {;-/(a,yi 01 6iz ',77
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/24/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Cremains to be
pI 05 )11 e►lure _ pot numb) (grave number)
Name of Sexton or Person in Charge of Premises G fir, cr L 'r'
(p ilease print)
LII Signature ,./( h Title ( 411442
(over)
DOH-1555 (02/2004)