Newton Jr., Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .:..,. Burial - Transit Permit
' Name First Middle Last Sex
Robert J. Newton,Jr Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 30, 2017 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village South Glens Falls Street Address 217 Main Street
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Dr Aqeed Gillani,MD
Address
Glens Falls,NY
i Death Certificate Filed District Number Register Number
>%, City, Town or Village South Glens Falls 4524
❑Burial Date Cemetery or Crematory
September 1, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
0, and/or Address
Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
y Remains are Shipped, If Other than Above
Address
1.1
" Permission is hereby granted to dispose of the human rem.' described ab as indicated.
Date Issued 0q'i 1 I-7 Registrar of Vital Statistics if ,/ 66/
(signature)
District Number q Place ll►�j 1 i, C � � T� �
I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on:
W Date of Disposition q j( In Place of Disposition fmt•I J em¢'iefw
2 (address)
W
U)
CL (section) (1(Igt number)( (grave number)
pName of Sexton or Person in Charge of P emises !+ J'Mitt
Z rr, (pl ase print)
W Signature 0 Title /Rfml
(over)
DOH-1555(02/2004)