Congdon, Robert r r v
A # 60 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Robert Clyde Congdon 1 Male
Date of Death 1 Age If Veteran of U.S.Armed Forces,
6/29/2016 !84 War oDates -
Place of Death Hospital. Institution or
City, Town or Village GYLE ; Street Address Washington Center
Manner of Death Natural Cause []Accident Homicide ®Suicide nUndetermined ®Pending
Circumstances Investigation
w Medical Certifier Name Title
C3 Jennifer Hayes
Address
4573 State Route 40 Argyle,New York 12809
Death Certificate Filed '-District Number S 0 i Register Number
City,Town or Village South Glens Falls 7Si 0`1'
[burial Date Cemetery or Crematory
7/1/2016 Pine View Crematory
DEntombment Address
OCremation 21 Quaker Road,Queensbury New York 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
-� Date Point of
1❑Transportation 1 Shipment
a by Common i Destination
Carrier
[]Disinterment Date Cemetery Address
0
Reinterment Date Cemetery Address
Permit Issued to ; Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home - South Glens Falls 101078
Address
136 Main Street, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address
CC
Ili
IL Permission is hereby granted to dispose of the human sins described above as Indicated.
Date Issued r/i) I a e!(o Registrar of Vital Statistics }� •
(srgnatura)
District Number 5 7S6 Place C „4 i ifi �\i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
US Date of Disposition Place of Disposition
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
z (plats*Pint)
ma Signature Title
(over)
DOH-1555(02/2004)