Fosmer, Robert NEW YORK STATE DEPARTMENT OF HEALTH �7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Harry Fosmer Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/27/2017 78 Years 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 Accident Homicide Suicide ri Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Bergin DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 688
El Burial Date Cemetery or Crematory
01/08/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
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 remains described above as indicated.
Date Issued 01/08/2018 Registrar of Vital Statistics Robert A Curtis(ECectronica1tySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition j J io(l g Place of Disposition eke ki r
(address)
(section) /I (Igt number)( (grave number)
Name of Sexton or Person in Charge of Pre .ses
,sJ (pl se print)
Signature
Title Nifritn
(over)
DOH-1555 (02/2004)