Aikens, Robert S1 S`
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Robert Aikens Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 19, 2011 95 War or Dates WWII
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death X Natural Cause Accident H Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
O Bernardo Villijuan,MD
Address
48 East Street,Fort Edward,NY 12828
Death Certificate Filed District Number {{Register Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
November 21, 2011 Pine View Crematory
❑Entombment I Address
Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I Removal , I and/or Held
O and/or Address
Hold
O Date ' Point of
NI 1 Transportation , Shipment
a by Common Destination
Carrier
Disinterment Date ! Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
2 Address
uul
Permission is hereby granted to dispose of the human remains described ove as indicated.
Date Issued l.0--t Ic IN Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Nod 221 wit Place of Disposition i",ntVlty) C.carretOrlv�,
2 (address)
W
to
Q(Y (section) i1"-(lot number (grave number)
Name of Sexton or Person in Charge of Premises t,S3OJt' JIeM�
'LJ
Z / (please print)
Signature ,,, .. Title aOnPsiat.
(over)
DOH-1555(02/2004)