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Elder Sr., Robert NEW YORK STATE DEPARTMENT EAL Vital Records Section Burial - Transit Permit Name First - Last Sex Male Robert Matthew Elder Sr. Date of Death If Veteran of U.S. Armed Forces, 12/09/2018 • - War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing Manner of Death©Natural Cause El Accident Homicide El Suicide riUndetermined Pending Circumstances Investigation Medical Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 171 ❑Burial Date Cemetery or Crematory 12/11/2018 Pine View Crematory ID Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination Carrier Date Cemetery Address ❑DisinterTent ,a Q Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 $A: 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 remains described above as indicated. Date Issued 12/10/2018 Registrar of Vital Statistics Caroline If Barber(ECectronica1TySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition /...�it—/cr Place of Disposition pikt, v rf;n,c,-f ccv (address) (section) (lot number) (grave number) Name of Sexton or Per on in Charge of Premises �PCrutL�' 5��;;CCS (please print) 1 Signatures Title (over) DOH-1555 (02/2004)