Pearce, Robert NEW YORK STATE DEPARTMENT OF HEALTH if71 Vital Records Section
Burial - Transit Permit
`- Name First Middle Last Sex
Robert James Pearce Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/25/2018 65 War or Dates
Place of Death Hospital, Institution ori2 ir.SPi7.--
City, Town or Village Btrent Lie //(If(i3O-7') , Street Address Deceased's Residence
Manner of Death a Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Terry M Comeau, Co/ow-el.`
-,'4'.,: /3 wo TirIss Re.7.7e, 7 / k aeile„ ., ..4 ._y/)...sc›, L,r
Death Certificate Filed District Number Re ist r Number
g b
.x City, Town or Village /�!/ co�� Sao 5 4
❑Burial Date or Cre tory /D
09/26/2018 Ge z0 2��! 7��'I4.`v!!c.."
❑Entombment Address
®Cremation aa,e,,e/IrkciC,i, _/(Z- /4)-709 ./.
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
,, " Date Cemetery Address
❑ Reinterment
y 3W
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
R 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 rem ' s described a ve as i icated.
Date Issued Ct. (0'I �' Registrar of Vital StatistiCr
(signature)
District Number 5-(a5-(a� Place �Y-� !�>,.�,
rm
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 l ti 11$ Place of Disposition ;ftu,,,., �w �
(address)
ca, (section) of number) (grave number)
Name of Sexton or Person in Charge of Premises ___ r.+ L-f S s-`11
(pledse print)
< Signature 4 Title ChW'Vi
(over)
DOH-1555 (02/2004)