Fenimore, Robert 57
NEW YORK STATE DEPARTMENT OF HEALTH'"'
Vital Records Section ;IIW f Burial - Transit Permit
Name First s's e Last Sex
Robert Louis Fenimore Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/18/2016 73 years War or Dates Vietnam
Place of Death Hospital, Institution or
Z City, Tq(4)@t WO( Glens Falls Street Address Glens Falls Hospital
Manner of Death Q Natural Cause El Accident El Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
O William Cleaver Attending Physician
Address
100 Park St Glens Falls, Ny 12801
v. Death Certificate Filed District Number Register Number
City, Td(001.NEW Glens Falls 5601 31
❑Burial Date Cemetery or Crematory
❑Entombment 01/20/2016 Pine View Crematory
Address al
[ 'Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
42 ❑and/or Address};;
11) Hold
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
mi Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Cr
111
Permission is hereby granted to dispose of the human remains descr'bed abo a 'cated.
Date Issued 01/20/2016 Registrar of Vital Statistics ‘ejt-
`�
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition I /ZI Ili. Place of Disposition 4?La (.eyn,Aarja,,._
(address)
iii
U) —
1X (section) lot number) (grave number)
ci Name of Sexton or Person in Char a of Premises ` /i(,5 � �g✓�+
Z (pleaAe print)
ill Signature t'1 Title (a�K}
(over)
DOH-1555 (02/2004)