Worth, Robert NEW YORK STATE DEPARTMENT OF HEALTH Q
Vital Records Section , Burial - Transit Permit
Name First Middle Last Sex
Robert 0 Worth Male
Date of Death Age i If Veteran of U.S. Armed Forces,
,; October 30, 2011 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined IT Pending
Circumstances Investigation
! . Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
fii, Death Certificate Filed Disilt in
R umber
• City, Town or Village
• ❑Burial Date Cemetery or Crematory
November 1, 2011 Pine View
• ❑Entombment Address
- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
0 and/or Address
Hold
Date Point of
j❑Transportation Shipment
It by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
{te Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home
fs Address 01078
ig
' 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains desc 'b d o as ' ted.
Date Issued / 0/ 2 21/ Registrar of Vital Statistics
(signature)
District Number L 2/ Place �,�� /--;7
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11/01/2011 Place of Disposition Quaker Road Queensbury,NY 12804
t ; (address)
(section) (lot nur) (grave number)
w Name of Sexton or Person in Charge o Premises f liosiiit
r #' rt}r
7J( L_
Signature Title (1/E WA
(over)
DOH-1555 (02/2004)