Labrum, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,, Burial - Transit Permit
Name First Middle Last Sex
Robert James Labrum Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 17, 2012 70 War or Dates
IE Place of Death Hospital, Institution or
W City, Town or Village Hudson Falls Street Address 16 North Street
W Manner of Death u Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Darci Gaioth-Grubbs, Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5726 04
0 Burial Date Cemetery or Crematory
March 19, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
0 Date Point of
0. ❑Transportation Shipment
GO by Common Destination
p; Carrier
Date Cemetery Address
El 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
fie
E" Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued Mar. 19 2012 Registrar of Vital Statistics -...f....a3—
(signature)
District Number 5726 Place Village of HudsonFalls, NY 11sh.3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
{w Date of Dis ositionDisposition ?;ne rJ yew Cie hntiik-�r':i inn
p 3�o 1 Z Place of
2 (address)
W:
(section (lot number) (grave number)
a ��
C Name of Sexton or Person in Charge of remises I t`WLOi"y rt-e
Z -d (please print)
W` Signature Title:4 �4PvIc�nb� -
(over)
DOH-1555 (02/2004)