Price Sr., Robert bL
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section rw
Name First Middle Last Sex
Robert Allen Price Sr. Male
Date of Death i Age , If Veteran of U.S. Armed Forces,
1 0/2 5/2 01 7 61 i War or Dates
"la-t ' Hospitala. , Institution or
Place of Death P 49 Saratoga Ave
Cit_ ity,°Town or Village South Glens Fall
Fatreet Address
Manner of Death nj Natural Cause 0 Accident 0 Homicide 0 Suicide LTA El Undetermined 0 Pending
Circumstances Investigation
uj, Medical Certifier Name Title
I, t ! (Ne‘
Address + �� t d g l
l '' a, P _ ---- w-.
Death Certificate Filed d --tom— ---- r- District Number Register Number
City, Town or CCille ----s A� t ii{Sa 4 /`.t
®Burial I Date i Cemetery or Crematory
Fntambrnent; Address
[ Cremation ' '
_Date . -_._�_r__ _�_ lace Removed M.B. Kilmer Funeral Home
' 7 Removal 1 0/2 7/2 01 7 and/or Held
and/or Address
Hold 136 Main St. South Glens Falls, NY 12803
Date i Point of
0 Transportation f Shipment
a by Common Destination
Carrier _ —
fl Disinterment Date I Cemetery Address
E Reinterment
Date I Cemetery Address
Permit Issued to M.B. Kilmer Funeral Home Registration Number
Name of Funeral Home
01078
Address 136 Main St. South Glens Falls 12803
_
Name of Funeral FirmMaking Dis osition or to Whom
_ Remains are Shipped, If Other than Above
$ Address
Ir
la
Permission is hereby granted to dispose of the human remain scribed ab• a as in.teated.
' Date Issued if 0-a r7- I Registrar of Vital Statistics 44,4�> : -
(signature)
District Number
qvy Place Vt l to o--f ,5:2uttl 3A*i ONS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1.11 Date of Disposition (ill 111 Place of Disposition 'f, �I
r„i4,J (r�'r*2"00.••.
(address)
Lit
{ser_t+omt (let number) r (grave number)
Name of Sexton or Person in Charge o Premises _ -_____ ....._ _._ If`` H.ni'
,)
2 'plea a pnnt)
Signature _ _ . Title ._. tVtint1
(over)
DOH-1555 (02;2004)