Davis, Robert , NEW YORK STATE DEPARTMENT OF HEALTH• t 19
Vital Records Section Burial - Transit Permit
q: Name First Middle Last Sex
4.4. Robert Russell Davis Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 3, 2018 50 War or Dates
i'd Place of Death Hospital, Institution or
City, Town or Village Kingsbury Street Address 579 Vaughn Road
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
LW P.:
Medical Certifier Name Title
P< Peter (moray Mr)
3 nrr Address
r
Death Certificate Filed�pp �ll /801 District Number Register Number
00 City, Town or Village .5 7 4 n j
0 Burial Date Cemetery or Crematory
March 5, 2018 Pine View Crematorium
ij 0 Entombment Address
I Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
,, '❑ Removal and/or Held
fe and/or Address
Hold
F 4, Date Point of
ru e ❑Transportation Shipment
,-9 by Common Destination
ter.
Carrier
0 Disinterment
Date Cemetery Address
,❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
414 Address
i Carleton Funeral Home, Inc. 68 Main St, P. O. Box 67 Hudson Falls, NY 12839
:14`',' 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 huma a described above as indicated.
Date Issued 3 S'/' Registrar of Vital Statistics 2S C s ). ci.
(signature)
r District Number 576 02, Place Q
I certify that the remains of the decedent identified ab ve were disposed of in accordance with this permit on:
t,
ui Date of Disposition 03/05/2018 Place of Disposition Quaker Road Queensbury,NY 12804
!"„ : (address)
WI
.r (section) A (lot number) f., (grave number)
4 Name of Sexton or Person in Charge of/Premises ! /Cn"
. ilease print)
Signature Title p1Uk-
(over)
DOH-1555 (02/2004)