Levack, Robert k79/2812816 12:19 5183773446 1 ih LIGHTS FUNERAL HOME ?OS-- PAGE 01/01
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Robert Paul Levack Male
`.,,i;; Date of Death Age If Veteran of U.S.Armed Forces,
09/26/2016 85 War or Dates 1952-1954 __
Place of Death Hospital, Institution
rZ City,Town or Village• City of Albany or Street Address Albany Medical Center
Manner of Death Natural Undetermined Pending 0 ® ❑ Accident ❑ Homicide 0 Suicide ❑ ❑ g
W) Cause Circumstances investigation
Medical Certifier Name Title
ict Tarek Dakakni MD.
i Address
43 New Scotland Ave. Albany, NY 12208
:.h'' Death Certificate Filed District Number Register Number
i City,Town or Village City of Albany 101 1992
Date Cemetery or Crematory
❑ Burial 09/29/2016 Pine View Crematorium
❑ Entombment Address
®Cremation Queensbury, NY, _
fDate Place Removed
Z Removal and/or Held
❑ and/or Address
I- Hold
of
D. Transportation .Date Shipment
Cl) ❑ By Common Ship
Point
C] Carrier Destination
El Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To • Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
,'!' 407 Bay Rd. Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
uJ',
a., Permission is hereby granted to dispose of the human remains describe above as indica
Date 09/28/2016 � �
Issued Registrar of Vital Statistics -''' ��K� i
(signature)
District Number 101 Place City of Albany, NY
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iy Date of Disposition 9J /`i& Place of Disposition .PjQ Li►>1 e� Ociri-e. 'y
w / (address)
Ell
of .
0 O (section) (lot number) (grave number)
o w Name of Sexton or Pe on in Charge of Premises Lc,bk,vi f e
(please print)
Signature it/ Title G�fr4a,J.0/
(over)
DOH-1555(02/2004) .