Jordan, Robert NEW YORK STATE DEPARTMENT OF HEALTH . ', it Lr/4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Jordan , Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 12, 2012 66 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
0 John P. Stoutenburg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nuneti o l Regi f ber
City, Town or Village
0 Burial Date Cemetery or Crematory
September 13, 2012 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold
GI Date Point of
t ❑Transportation Shipment
.41 by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
l
CL Permission is hereby granted to dispose of the human remains descr' d bo as ' ated.
1-< Date Issued Ov 3�2o/2- Registrar of Vital Statistics _
(signature)
District Number S / Place �:y,,q A, AIX I-)<10 t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/13/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /� _(lot number)
(grave number)
Name of Sexton or Person in Charge o Premises L ti ns r Jt
please print)
Signature Title .Wit
(over)
DOH-1555 (02/2004)