Massett, Robert NEW YORK STATE DEPARTMENT OF HEALTH <° '
Vital Records Section '"• ' Burial - Transit Permit
Name First Middle ., ° Last Sex
Robert Philip ir Massett Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/14/2016 90 years War or Dates
I— Place of Death Hospital, Institution or
City, T Street Address
UJ ° � Saratoga S rings Sarato a H s ital
W Manner of Death L J Natural Cause 11 Accident Q.Homicide 0 Suicide u undetermined 0 Pending
�-J� Circumstances Investigation
W Medical Certifier Name Title
0 Zeshan Latifima M D
Address
211 Church Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, To Vii Saratnda Springs A601 95
❑Burial Date Cemetery or Crematory
❑Entombment 02/17/7016 Pine View Crematory
Address
LiCremation Queensbury, N Y
Date Place Removed
Z ❑Removal and/or Held
and/or Address
N Hold
O Date Point of
N❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan 01821
Address
11 Algonkin St. , Ticonderoga NY 12883
Name of Funeral Firm Making Disposition or to Whom
IF- Remains are Shipped, If Other than Above
2 Address
LC
W
CL Permission is hereby granted to dispose of the human remai a ri d abnrp 'ndicate
Date Issued 02/17/2016 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W• Date of Disposition 2(11Il` Place of Disposition „Pa it../ of ctoCw►—
2 (address)
W
co
O )(section /f (lot numb (grave number
p Name of Sexton or Person in Char a of Premises �Ht., s�"+�''�' )
Z /'� ( lease print) •
W Signature [ti Title 1K
(over)
DOH-1555 (02/2004)