Nelson, Robert NEW YORK STATE DEPARTMENT OF HEALTH`
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Vital Records Section Burial - Transit Permit
zt Name First Middle Last Sex
Robert C. Nelson Male
l Date of Death Age If Veteran of U.S. Armed Forces,
07/15/2018 86 War or Dates Korea
' ,,� e of DeathHospital, Institutio o� 99� /� --"
►ty, own or VillageCAS v� ( S�"e�,
- g ewc..(-77-€1 Street Address
= ner of Death Undetermined Pending
1r X❑Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ ❑
,c Circumstances Investigation
Medical Certifier Name Title
PAUL BACHMAN,
Address
3767 Main ST. Warrensburg, NY 12885
Deat cate Filed District Number— Register Number
v Cit Town Village (d/cS/` �5 �'�. )--' /,?
4 , CI Burial Date r/.0 k) l /�l�4 fabt�
07/20/2018 //1 ��
matoniq
❑Entombment Address a �
7 //c-?/7
Y ®Cremation
U�'
Date Place Removed ,•
¢ Removal fil❑ and/or Held
and/or Hold Address
, Date Point of
❑Transportation Shipment
by Common Destination
0.' Carrier
Q Disinterment
Date Cemetery Address
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
,kiN Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
,# , Address
llf t 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he eby ranted to dispose of the human remains de ri eabove as indicated.
Date Issued / Registrar of Vital Statistics W
—r^ /� (signature
District Number ,St0Sa Place 1 �;U.l� 0' ' C, (S AT.-i7
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 7/ 3b.otd Place of Disposition t;ht,V;t.) Gfe 4ceici 'Y
s (address)
, (section) (lot number) (grave number)
z �t �mVy (��v�le.5
`' ' Name of Sexton or Person in Charge of Premises (please print)
Signature^ it.v-&-' Title
(over)
DOH-1555(02/2004)