Waters, Robert NEW YORK STATE DEPARTMENT OF HEALTH 47'I,3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert E. Waters Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 11,2015 69 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Bakers Mills Street Address 2118 State Route 8
W Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
0 Jennifer Donovan
Address
HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number 1 Register Number
City, Town or Village 5655
❑Burial Date Cemetery or Crematory
October 13,2015 Pine View Crematory
0 Entombment Address
❑X Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
u)
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1-1 Remains are Shipped, If Other than Above
2 Address
Ce
O.
Permission is hereby granted to dispose of the human ains described above as indicated.
Date Issued a aO�Registrar of Vital Statistics D a.
(signature
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui Date of Disposition (oligii6 Place of Disposition Fitt IL C�*s Or,w..W (address)
CO
O (section) (lot numb) (grave number)
p /• Name of Sexton or Person in Charge of Premises i4r,,V-- -It mot
Z (please print)
W Signature It Title Of OM
(over)
DOH-1555 (02/2004)