Labshere Jr., Robert NEW YORK STATE DEPARTMENT OF HEALTH"� 74/6
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert ECtward Labstiere Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/03/2017 56 WarorDates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 107 1 /2 Maple St
Manner of Death®Natural Cause 0 Accident 0 Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Robert D. Lemieux
Address 219 Pope Hill Rd, Argyle, NY 12809
Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 5•� 6 g,2 V
'Burial Date 10/05/2017 Cemetery ryor Cremator
y Pine View Crematory
0 Entombment
Address
®Cremation Quaker Rd, Queensbury, NY
Date Place Removed
ri Removal and/or Held
and/or Address
Hold
Date Point of
rt 1 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to M.B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01 079
Address 82 Broadway Fort Edward, NY 12828
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 human remai e ' ed above as indicated.
Date Issued l0-s 017 Registrar of Vital Statistics - 14.- c' ° '"e--______
(signature)
District Number slab Place -.\LA,0--e c�- 6 U as.1 -Fn.Q.9 -a
I certify that the remains of the decedent identified abovee disposed of in accordance with this permit on:
Date of Disposition /64'--/-7 Place of Disposition Pi)iL�ki, / er 4.4
(address)
(section) (lot numbbej (grave number)
Name of Sexton or P n in Charge of Premises i L- / 4 -i
(please print)
`! Signature Title ��e- ;4.,
(over)
DOH-1555 (02/2004)