Sanford, Jr. Robert # 35i
NEW YORK STATE DEPARTMENT OF HEALTH Burial Records Section Burial - Transit Permit
ii Name First Middle Last
Aae Robert W Sanford, Jr. Sex Male
Dt of Death € A e if Veteran of U.S. Armed Forces,
7/13/2011 1 16 War or Dates no
Place of Death Hospital, Institution or
i ORIC Town isnillicY0 Salem Street Address 4383 State Rte. 29
Manner of Death 0 Natural Cause 60 Accident 0 Homicide 0 Suicide Q Undetermined Pending
Circumstances Investigation
. Medical Certifier Name Title
Michael Sikirica Medical Examiner
Examiner
.47
J Address
,, 50 Broad St., Waterford, NY
. Death Certificate Filed District Number Register Number
¢G Town off` Salem 5? C
Date ' Cemetery or Crematory
❑Burial 7/18/2011 Pine View Crematory
Address
Cremation Queensbury,NY
Date Place Removed
2 o Removal t and/or Held
••• and/or Address
Hold
Date ' Point of
QTransportation Shipment
by Common i Destination
Carrier
Disinterment Date ' Cemetery Address
'': Reinterment Date Cemetery Address
Permit Issued to 4 Registration Number
;: z Name of Funeral Home Brewer Funeral Home, Inc. 1 00211
la Address
¢: 24 Church St., Lake Luzerne,NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ii Permission is hereby granted to dispose of the human remains( described above as indicated.
1J', Date Issued b�-)3'at41 Registrar of Vital Statistics -C k ' l.3*
Ns: (signature)
: �-1
(:3 District Number. /fsj�! Plac e l TJ� g�
I certify that the remains of the decedent identified above were dispose/d�of in accordance with this permit on:
Date of Disposition 1 /15 Il i Place of Disposition "v J Cwh-c o r ..
(address)
CA
(section) /9 (4ot num er) (grave number)
84 Name of Sexton or Person in Charge of remisesin l h r KA hr r nruli-
$ (please print)
i
L
. Signature rf(" Title G eiti}Tve
DOH-1555 (10/89) p. 1 of 2 VS-61