Williams, Robert MIIIIIIP"" ! I . v
NEW YORK STATE DEPARTMENT OF HEALTH t /3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Elmer Williams Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/16/2016 64 years War or Dates 1974-1976
1.0 Place of Death Hospital, Institution or
• City, T]Q�Xt)Obr Q) X Glens Falls Street Address Glens Falls Hospital
0 Manner of Death gNatural Cause ❑Accident El Homicide ❑Suicide El Undetermined ri❑Pending
W. Circumstances Investigation
ill Medical Certifier Name Title
0 Eric Pillemer M D
Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TXXX6rXtfiltlig Glens Falls 5601 86
❑Burial Date Cemetery or Crematory
02/17/2016 Pine View Crematory
❑Entombment Address
['Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
.14❑and/or Address
N Hold
O Date Point of
tJi❑
Transportation Shipment
L by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
>I> Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
a Address
te
ICE
` Permission is hereby granted to dispose of the human r mains de ribed airve as indicated
Date Issued 02/17/2016 Registrar of Vital Statistics zyZ j G-! -�
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
&tllq.'
I� Date of Disposition Zt(° t i, Place of Disposition Gs"•
a (address)
III
('I
re (section) /' (lotnurpier) (grave number)
CI Name of Sexton or Person in Charge of Premises izr J\°t at
2 /h please print)
14 Signature Gr( ��l Title atekbiftR4
(over)
DOH-1555 (02/2004)