Bolinder Jr, Robert NEW YORK STATE DEPARTMENT OF HEALTH1b®
Vital Records Section .s• . n44. Burial - Transit Permit
j Name First Middle Last Sex
Robert David Bolinder Jr. Male
- ` Date of Death Age If Veteran of U.S. Aftied Forces,
",-."::1 September 12, 2016 84 War or Dates Tl r
Place of Death Hospital, Institution or
'' City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death
Medical Certifier
Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined I I Pending
Circumstances Investigation
Name Title
Philip J.Gara Jr. MD
Address
'''327 Broadway,Fort Edward,New York 12828
'A%,
5 Death Certificate Filed Distri�LNui b Regis/te Number
`If J 1.� 'f r%;r City,Town or Village
0 Burial Date Cemetery or Crematory
❑Entombment September 15, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
O
and/or Address
E
Hold
U)
o Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
IA Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
i:{ Address
.' 1 407 Bay Road, Queensbury,NY 12804
F Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the h- a Ai-Mt ins rdescr�'b�d�ab ve as indicated.
E'�< � to Issued R—� � Registrar of Vital Statistics W�►� Y '
_ (signature)
District Number 5/65 Place rCr--L ECIWOAd
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition 11114 46 Place of Disposition gi0 t p*
(address)
W
CO
et (section) /(lot number) c ��e (grave number)
pp• Name of Sexton or Person in Charge of Premises 7( j c_)l"t'7
Z ( ase print)
Wa „.4._Signature Title Cwtj7Ue
(over)
DOH-1555(02/2004)