Newman, Robert 08 4 yg
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Mi Name First Middle Last Sex
Robert Allen Newman Male
Date of Death Age If Veteran of U.S. Armed Forces,
7-3-2016 85 War or Dates YES
Place of Death Hospital, Institution or
211 Lisa Drive
t City, Town or Village Gansevoort NY Street Address
a Manner of Death E Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
iii Circumstances Investigation
til Medical Certifier Name Title
G>I Thomas Coppens MD
Address
3 Irongate Center Glens Falls, NY
Death Certificate Filed District Number Regir Number
City, Town or Village Tn. of Moreau � (� p I
❑Burial Date Cemetery or Crematory
7-7-2016 Pine View Crematory
❑Entombment Address
di [Cremation 21 Quaker Road Queensbury, NY
Date Place Removed
❑Removal and/or Held
9and/or Address
Hold
0 Date Point of
iTransportation Shipment
L1 by Common Destination
Carrier
gii
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01078
Address
136 Main St. South Glens Falls, New York 12803
iiIllIl Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ir
ttf
n` Permission is hereby granted to dispose of the human remai escribe bo as indicated.
Date Issued 7-7-2 01 6 Registrar of Vital Statistics iajjll.,(
(sign re)
District Number 1490 Place Tn. of Moreau, New ork
I certify that the remains of the decedent identified above were disposed of i accordance with this permit on:
Ill Date of Disposition 7 17 I IL, Place of Disposition fist1f '",✓ trlrrn ►..4.,
2 (address)
ill
CO
CC (section) (lot number (grave number)
CI Name of Sexton or Person in Charg of Premises A4) t"''`11
2 (please print) �t
Signature Title Ct7,E� 1 --
(over)
DOH-1555 (02/2004)