Mone, Robert NEW YORK STATE DEPARTMENT OF HEALT. # 640
Vital Records Section s s Burial - Transit Permit
Name First Middle Last Sex
Robert Mone Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 25, 2011 80 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC.
W' Manner of Death m
Eki Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
Barney Rubenstein MD,
Address
51 South Union St. Cambridge, NY 12816
Death Certificate Filed District Number 5,2s-O Register Number
�p City, Town or Village
❑Burial Date Cemetery or Crematory
December 28, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
" Date Point of
❑Transportation Shipment
O by Common Destination
13 Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2` Address
LL>
W:
Permission is h reby granted to dispose of the human re s describe��as indicated.
Date Issued 1v271// Registrar of Vital Statistics
(signature)
District Number570 Place d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W` Date of Disposition/ 3b- ,t( Place of Disposition RYle crew/Q:40,f
(address)
t
(section) !1(lot number) (grave number)
CIName of Sexton or Person in Char a of Premises j►ylpt�.( �7f'vno((?
(please print)
L I Signature 312 Title Cf"<Y 4 ACS
(over)
DOH-1555 (02/2004)