Homkey, Robert NEW YORK STATE DEPARTMENT OF HEALTH i ir `��o
Vital Records Section Burial - Transit Permit
><_ Name First Middle Last Sex
Robert J. Homkey Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 18,2016 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death n NaturalGlensFalls Cause Accident Homicide n Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
William Cleaver,MD
Address
Glens Falls,NY
»'.' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 2.G"
❑Burial Date Cemetery or Crematory
April 25, 2016 Pine View Crematorium
III Entombment Address
O Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZG ❑Removal and/or Held
and/or Address
—I= Hold
U)
Q Date Point of
N U Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
`� Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
;'. Address
4• 07 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
'`"! Remains are Shipped, If Other than Above
A• ddress
i
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (-4 (( c( I it Registrar of Vital Statistics 11 .):.A cam'
(signatur )
District Number 56c� Place 6j CQJV.S `, S / � y
I certify that the remains of the decedent identified above were disposed of inaccordance with this permit on:
WDate of Disposition (1 I Zql/(, Place of Disposition r'igOfL., Li-6-4D'--
2 (address)
W
U)
W (section) A (lot num (grave number)
pName of Sexton or Person in Charge f Premises rI WI'/
Z 7 •(please print)
iti
Signature Title '+� i7
(over)
DOH-1555(02/2004)