Dufault, Robert NEW YORK STATE DEPARTMENT OF HEALTH ` W 313
Vital Records Section Burial - Transit Permit
« Name First Middle Last Sex
Robert Lee Dufault Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 24, 2018 81 yrs . War or Dates No
14 Place of Death Town of Hospital, Institution or 6 Sno Pappy
City, Town or Village Hag„' Street Address
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
ui Medical Certifier Name Title
Kathleen P. Huestis M.D.
Address
102 Racetrack Road, Ticonderoga, New York 12883
Death Certificate Filed Town o f District Number Register Number .Z
in City, Town or Village Hague 5653 Z.
'> ❑Burial Date Cemetery or Crematory
4/26/2018 Pine View Crematory
i ; Entombment Address
giii ®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
t: Hold
f
Date Point of
Transportation Shipment
L by Common Destination
Carrier
❑Disinterment Date Cemetery Address
: Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
i Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
;, Address
IX
t
aL
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4/2 5/2 018 Registrar of Vital Statistics `---, cz� _ 7-7�
f (signature)
District Number5653 Place Town of Hague t/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
ILI Date of Disposition N jr,(li Place of Disposition ,�, r�.,.,d 4c4rc...
2 (address)
til
CC (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises �+ -- 4*
(pl ase print)
LT,i d
Signature 4Title 6+4tfp'L
(over)
DOH-1555 (02/2004)