Farry, Robert NEW YORK STATE DEPARTMENT OF HEALTH 80
Vital Records Section Burial - Transit Permit
'►�--1
Name First Middle Last Sex
i Robert Farry Male
.-; Date of Death Age If Veteran of U.S. Armed Forces
_7'- May 31, 2011 73 War or Dates
Place of Death Hospital, Institution or
t City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 1771.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined In❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs, M.D Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District NumberRegister�l}a �r
City, Town or Village �,�EJJ d//" Aa//
0 Burial Date Cemetery or Crematory
: June 1, 2011 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
❑Transportation Shipment
by Common Destination
Carrier
s ❑ Disinterment
Date Cemetery Address
a❑ Reinterment Date Cemetery Address
Iii
. Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01097
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
iq Address
Permission is hereby granted to dispose of the human remains descrielayweity intInZ._
3 Registrar of Vital Statistics
Date Issued 9 � 1/
(signature)
District Number / r-
�d� Place �le�s l4//y A2c9fl
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 06/01/2011 Place of Disposition Quaker Road Queensbury,NY 12804
' (address)
(section) (lot n�uum-ber) (grave number)
Name of Sexton or Person in Cha ge of Premises i1 r,s r 5t'+rtpt
I (please print)
Signature Title ralikilft
(over)
DOH-1555 (02/2004)