Thompson, Robert NEW YORK STATE DEPARTMENT OF HEALTH' 31 i
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
iiiiiii Robert James Thompson Male
`f Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2015 _ 88 War or Dates
6.... Place of Death Hospital, Institution or
Town or Fort Ann Street Address 1653 Mattison Rd, Fort Ann, NY
I Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
CI Daniel Eldridge MD
€I Address
iiiiiiii 3044 Rte 50, Saratoga Springs, NY 12866
i:i Death Certificate Filed District Numbe, -^ Registef_u r
it N9c Town or MOW Fort Ann / if
Date Cemetery or Crematory
❑Burial 04/27/2015 Pine View Crematorium
Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
0�Removal and/or Held
••.. and/or Address
0
Hold
O Date Point of
N❑Transportation Shipment
8 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
imi Permit Issued to Registration Number
iiiiiii. Name of Funeral Home Mason Funeral Hare- 01117
Mi Address
18 George Street, PO Box 277, Fort Ann, NY 12827
``' Name of Funeral Firm Making Disposition or to Whom
lit Remains are Shipped, If Other than Above
i* Address
tii Permission is hereby granted to dispose of the human re ns described abov-j cated.
iligDate Issued fi""a7 ors Registrar of Vital Statistics 1,4_ �i1��
iiii (sign re)
`> District Number 9- Place ti_ L
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F �^
W Date of Disposition gl itiic Place of Disposition ,r;uu,.,, 'r+.iv,_
2 (address)
W
UJ
CC (section) (lot number (grave number)
AName of Sexton or Person in Charge of Premises } �,.,
v (please print)
LI: Signature i� ,A.... Title Carofol,
DOH-1555 (10/89) p. 1 of 2 VS-61