Roberts, Richard NEW YORK STATE DEPARTMENT OF HEALTH' • ' ` // (ego
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard John Roberts Male
- Date of Death Age If Veteran of U.S. Armed Forces,
September 10, 2015 68 War or Dates
ti Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
Sean Bain, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number o�-y� Register r,47,irr
City, Town or Village Glens Falls J(�
/
❑Burial Date Cemetery or Crematory
September 15, 2015 Pine View Crematory
"❑Entombment Address
`f ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
w Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 1 l W J 15 Registrar of Vital Statistics (iO0k,k4y,ek.sk)
(signaty
District Number ` Place 6 S Vo,\\ w 0
/
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
. .+ Date of Disposition 09/15/2015 Place of Disposition Quaker Road Queensbury,NY 12804
t
(address)
A.
• (section) 4, (lot number) (grave number)
I, }
Name of Sexton or Person in Charge of remises nstplxi S.rnna "
�/ lease print)
Signature �1�� Title filfaiitt
(over)
DOH-1555 (02/2004)