Luaces, Robert NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
;:r; N• ame First
Middle Last Sex
::i Robert L. Luaces Male
f1 Date of Death Age If Veteran of U.S. Armed Forces,
January 21, 2016 69 War or Dates
-: P• lace: of Death
r Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
:,r Eric Pillemer,MD
Address
rr:; 100 Park Street,Glens Falls,NY 12801 r... Death Certificate Filed District Number F � Register Number
.)
City, Town or Village c�.l
❑Burial Date Cemetery or Crematory
January 22,2016 Pine View Crematorium
❑Entombment Address
I1 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
t- Hold
N
o Date Point of
NI I Transportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
::' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
f: Address
53 Quaker Road, Queensbury,NY 12804
✓ r Name of Funeral Firm Making Disposition or to Whom
rr:
: Remains are Shipped, If Other than Above
Address
.rr Permission is hereb granted to dispose of the human rem ins described abov as indicate .
• Date Issued Registrar of Vital Statistics ./ (. /rl
rr (sign ure)
COO
District Number Place (x--▪.. ?y' I certify that the remains of the decedent identified above were di osed of in accordajce with permit on:
I -
Z ,f XIJA..../I
W Date of Disposition I i ZDs11b Place of Disposition 42-.,
2 (address)
W
U)
CC
0 (section) J (lot number , (grave number)
fa Name of Sexton or Person in Char a of Premises ��r,1, Je t
G
Z /�� ( lease print)
Signature Gf/` w I Title 17 ntit
(over)
DOH-1555(02/2004)