Mercier, Robert NEW YORK STATE DEPARTMENT OF HEALTH 1 , 1 it 37
Vital Records Section Burial - Transit Permit
", Name First Middle Last Sex
Robert William Mercier Male
Date of Death Age If Veteran of U.S. Armed Forces,
= May 5, 2017 --)-5- War or Dates
----ac of Death Hospital, Institution or
Ci City own or Village G I c , S E—„ t, t i Street Address
Manner of Death dNatural Cause ❑ Accident ❑ Homicide El Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
Dean Reali, M.D
Address
Hudson Headwaters Warrensburg, NY 12885
D--th Certificate Filed _ District Number Re ister er
;+ City)Town or Village Gg( ens I—�C is 5—G 0( p
ff '❑Burial Date Cemetery or Crematory
May 8, 2017 Pine View Crematorium
x. ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
2 ❑ Removal and/or Held
and/or Address
p, Hold
Date Point of
A. ❑Transportation Shipment
by Common Destination
G Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
1,11
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Ad
ff Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
J= Remains are Shipped, If Other than Above
Address
W
n Permission is hereby granted to dispose of the human remains desc 'bed b a ' ated.
Date Issued (,'t1'/08�2D/�7 Registrar of Vital Statistics j,�, G✓ `
(signature)
District Number 5.60/ Place 67rs., n/,( /04
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wi Date of Disposition 05/08/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
:
® ; (section) /. (lot number) (grave number)
la-Ter Name of Sexton or Person in Charge of Pr mises l �rs T �4 ►C If
(p ase print)
W' Signature VT Title lkr-n11 c
(over)
DOH-1555 (02/2004)