Young, Robert Illli
NEW YORK STATE DEPARTMENT OF HEALTA 7l‘)
Vital Records Section Burial - Transit Permit
.. Name First Middle Last Sex
{rr: Robert J. Young Male
:::: Date of Death Age If Veteran of U.S. Armed Forces,
c.':: January 30, 2015 81 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
g Manner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
: .:3 Suzanne Rayeski MD
:r:.: Address
:::: 100 Park Street,Glens Falls,NY 12801
;;rr Death Certificate Filed District Number Register Number
e:;: City, Town or Village Glens Falls 5601 Y 7
..'❑Burial Date Cemetery or Crematory
February 2, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold •
CO
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
: ; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
.'.r 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1
r Permission is hereby granted to dispose of the human remains described above as indicated.
:::r
Date Issued Z/ 3 l 1 5 Registrar of Vital Statistics W cA-.�..� (A.L✓
:r': (signature)
:: District Number 5601 Place Glens Fallsd N}'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ' Place of Disposition t(11,,,) C{t,,..,
2 (Z-4- 1 (address)
LU N )s )
C / (section) • (lot nu ber) (grave number)
ca
G Name of Sexton or Person in Char a of Premises £A" ,3
Z R (please print)
W
Signature Title CP.PlItin
(over)
DOH-1555(02/2004)