Dopfel, Robert 3 . # zs7
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert F Dopfel Male
rrs Date of Death Age If Veteran of U.S. Armed Forces,
April 4,2016 45 War or Dates.
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 11 Elizabeth Lane
:121 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
MS Circumstances Investigation
1 Medical Certifier Name Title
Gerald F Abess
Address
Xi 3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Wister Number
j;§' City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment April 6, 2016 Pine View Crematory
Address
E Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rr Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford 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
Address
tli
Zti
Permission is hereby granted to dispose of the human remains described ab/ovvp(aas indicated.
d Zpa Date Issue ( ( p (p Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W '�Date of Disposition /-7-/(o Place of Disposition Q.Q Lif_ek) �
2 (address)
W
CO
pre (section) i // (lot number) (grave number)
Name of Sexton o Perso i Charge of Premises Lt-1;G..vt(�w ri7�(�lie_
Z (please print)
Signature Title G re.yr7c-71O/
(over)
DOH-1555(02/2004)