Stevens, Robert 07
NEW YORK STATE DEPARTMENT Or"HEAL-PH Vital Records Section Burial - Transit Permit
°",r Name First Middle Last Sex
Robert��, Peter Stevens Male
Date of Death Age If Veteran of U.S. Armed Forces,
'- August 22, 2016 CO3 War or Dates
f; Place of Death Hospital, Institution or
s City, Town or Village Glens Falls, NY
Manner of Death
Medical Certifier Name
Street Address 6 Hartford Ave
C Natural Cause Accident Homicide Suicide Undetermined C Pending
Circumstances Investigation
Title
;,.; Michael Sikirick,Coroner
Address
}f.< Albany,NY
,- Death Certificate Filed District Number Register Number
r r City, Town or Village Glens Falls, NY 5601 Li 03 3
❑Burial Date Cemetery or Crematory
❑Entombment August 25, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N Ill by
Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'%- Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
•! � Address
53 Quaker Road,Queensbury,NY 12804
: 4 Name of Funeral Firm Making Disposition or to Whom
1x, Remains are Shipped, If Other than Above
Address
r. Permission is hereby granted to dispose of the human remains described above as indicated./n1_
Date Issued .g1 Z4 �v , 'rQ
l 6 Registrar of Vital Statistics I.. . bra
(signature)
f District Number 56p , Place 6 ( ,v s V \\� t o T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILIDate of Disposition /2..i//b Place of Disposition , /'7eUt"eitiv ./e 1
2 (addre�ss)
co
0 (section) (lot number)� (grave number)
pName of Sexton or rson in Charge of Premises 4. �tGcc.42
Z (please print)
W Signature Title 6,,'ei-.2�-.kei�'
(over)
DOH-1555(02/2004)