Robinson, Richard NEW YORK STATE DEPARTMENT OF HEALTH �,4 76 Z
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Richard Earle Robinson Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 16, 2016 75 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Colonie Street Address 1366 New Loudon Rd.
Manner of Death Natural Cause 0 Accident ❑ Homicide 0 Suicide 1-1 Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
1 Timothy Cavanaugh,
Address
112 State Street Albany, NY 12207
Death Certificate Filed District Number /6 5 Register N-u ber
City, Town or Village Colonie is
_ 0 Burial Date Cemetery or Crematory
71 March 17, 2016 Pine View Crematory
❑Entombment
`� Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
a ❑Transportation Shipment
by Common Destination
a Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
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
i
Permission is here yy gr nted to dispose of the human i describel a in% d.
Date Issued // /0 Registrar of Vital Statistics /
(signature)
, ; District Number /5 5 Place C� C/e-X_J--el,
I
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 03/17/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
tzt
(section) Ai
(lot number) (grave number)
0 Name of Sexton or Person in Charge Premises go _co. t
z (pkase print)
ill Signature 6- Title I Wes&
(over)
DOH-1555 (02/2004)