Fitzgerald, Robert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
i Robert H. Fitzgerald male
Date of Death Age If Veteran of U.S. Armed Forces,G
..1 03/19/2018 ' War or Dates n/a
{•
Place of Death Hospital, Institution or
r„1 City, Town or Village Hadley
Street Address 6305 State 9N
k. Manner of Death Undetermined Pending
° x Natural Cause n Accident n Homicide Suicide Circumstances Investigation
:-.:Ze. Medical Certifier Name Title
';` Harry Lindman DO
Address
x: 200 Smith Drive Corinth, NY 12822
;: Death Certificate Filed District Number Register Number
T-,
r City, Town or Village P--3 Ad IS.T
❑Burial Date `� Cemetery or Crematory
03/20/2018 Pine View Crematory
❑Entombment Address
[ Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
2 and/or Address
h= Hold
09
Date Point of
N; Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
: Permit Issued to Registration Number
a Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address 407 Bay Rd Queensbury, NY 12804
: ; Name of Funeral Firm Making Disposition or to Whom
r;$ Remains are Shipped, If Other than Above
c7:7: Address
r
„1
Permission is hereby granted to dispose of the human r ains described above as indicated.
Jh
Date Issued 3.ao -j d' Registrar of Vital Statistics � t� C
(signature)
District Number VS"5'"e7 Place
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1�- �
:' Date of Disposition 3I 1211S Place of Disposition i',�� ' +—
2 (address)
W
(section) /j (lot number) (grave number)
g Name of Sexton or Person in Charge of Premises ( t•• "
41
J ( lease p nt)
Signature fl,,,y Title C('CAti I1&
(over)
DOH-1555(02/2004)