Robichaud, Patricia a 7L(
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
z% Name First Middle Last Sex
Patricia L. Robichaud Female
`< Date of Death Age If Veteran of U.S. Armed Forces,
August 11, 2016 79 War or Dates Korean
+ Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Warren Center
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Kenneth France MD
Address
1 100 Broad Street,Glens Falls,NY 12801
Death rtificate File s rict Number Register Number
,,, Cit , own o Village is j(IK— m
❑Bunar Date ( Cemetery or Crematory
August 12,2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
C 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
, Name of Funeral Firm Making Disposition or to Whom
f Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human e ains describedj1above as indicated.
Date Issued�l`` t�I�1(_o Registrar of Vital Statistics `-�c . �/� /1-
' ______1 (signature)
District Numbe '1 Place ) o �r_ sOcC--" L a 0 Q___)_ L-
I certify that the remains of the decedent identified above were disposed of in accordan e wit this permit on:
W Date of Disposition 45/t yil, Place of Disposition PO't Q 1O(84,0 Gce,'1 "7
W (address)
Cl)
o (section) 1\ / (lot number) (grave number)
pName of Sexton or P on in arge of Premises .J1,, 4,hzet( 9 E '4
Z (please print)
W Signature Title G 2h e.....4p1
(over)
DOH-1555(02/2004)