Robertson, Daniel _P c'L ' # 6Z7
NEW YORK STATE DEPARTMENT OF HEALTH I 1
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Daniel Robertson , Male
Date of Death I Age If Veteran of U.S. Armed Forces,
December 20, 2011 83 War or Dates
.. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 30 Fort Amherst
pManner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Dr.Richard Leach,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number 1 Re aster Number
City, Town or Village Queensbury,NY 5657 1 I , H
❑Burial j Date Cemetery or Crematory
December 21, 2011 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date j Place Removed
Z Removal and/or Held
O and/or ! Address
H Hold
U)
0 Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 Registration Number
_Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
!_- Remains are Shipped, If Other than Above
2 Address
CC
W _
-
o. Permission is hereby granted to dispose of the human rarpains described bpve as indicated.
Date Issued 1 Zl 2 1 Icy I I Registrar of Vital Statistics M% C , -_
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were dispos d of in accordance with this permit on:
W Date of Disposition pEc l7(700 Place of Disposition iN Vick C. oriu�.
2 (address)
W
U)
re (section) Likcplkl
(lot numbe (grave number)
pName of Sexton or Person in Charg of Premises r ¢ktl�Z /41please print)
W
Signature Title rearMyt-TUtl.
(over)
DOH-1555 (02/2004)