Geroux Sr, Robert NEW YORK STATE DEPARTMENT OF HEALTH 4 i A Tl
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Robert John Geroux Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 31, 2016 80 War or Dates
F— Place of Death Hospital, Institution or
Z Ci
W ty, Town or Village Glens Falls Street Address 9 Everts Ave
W Manner of Death xi Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
C Glen Anderson RPA-C,
Address
Moreau Family Health South Glens Falls, NY 12803
Death Certificate Filed District Number Regi -5rtr
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
November 1, 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
H' Hold
fA Date Point of
a ❑Transportation Shipment
0) by Common Destination
0' Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
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
W;
EL Permission is hereby granted to dispose of the human remains described above as indicated.
0
Date Issued } 1) 1 24.1) b Registrar of Vital Statistics Wovvicyet w
(signature)
District Number 5601 Place 6 (7.^S 'C1 1. 1.3, A/ 7
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 11/01/2016 Place of Disposition Quaker Road Queensbury,NY 12804
Z (address)
Wto
re''
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Afrii it-n k
® (please print)
W Signature �iG,a-+ Title AvemK
it-
(over)
DOH-1555 (02/2004)