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Robillard, Thomas ., ``la NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Thomas J. Robillard Male kit Date of Death Age If Veteran of U.S. Armed Forces, August 11,2017 69 War or Dates 7/19/1966-4/19/74 5., Place of Death Hospital, Institution or City, Town or Village Albany Street Address DVAMC 113 Holland Avenue Albany, NY 12208 ILI Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Danielle Pastor MD Address ," 113 Holland Avenue Albany, NY 12208 erg; Death Certificate Filed District Number Register Number City, Town or Village Albany 198 062 ❑Burial Date Cerrfftery or Crematory - ❑Entombment //�//7 �ls..��`-V Address 113Cremation 1(?_kA--OL-494A--) ,Q, Date Place Remov Z ❑Removal and/or Held - and/or Address Hold IA Date Point of in❑Transportation Shipment fl by Common Destination , ; Carrier tki- Date Cemetery Address Li Disinterment Reinterment11 r_i Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home - ---_- 'i B ��.Le (e Z Address (23 AttT iir AP filft , d`M- 1250 a Name of Funeral Firm Making Disposition or to Whom It Remains are Shipped, If Other than Above Address 14 Permission is hereby granted to dispose of the humar4eMaip§de `cr e a ,e7ACndicated. a e Date Issued August 11,2017 Registrar of Vital Statistic 5t (signature) District Number 198 Place DVAMC, 113 Holland Avenue, Albany,New York 12208 44.7 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ! Date of Disposition 2111,In Place of Disposition e -U p,w Lww.444;'r,N, i (address) CO $ (section) 1(lot number) (grave number) Name of Sexton or Person in Charge of P emises (4gis-� r S . �^ (p/e print) Signature 4I Title P�gillip (over) DOH-1555 (02/2004)