Hipwell, Robert 10/2912012 1E:03 5183773446 LIGHTS FUNERAL HOME PAGE 01
IN
NEW YORK STATE DEPARTMENT OF HEALTH It .�
Vital Records section Burial - Transit Permit
Name First Middle Last Sex
Robert G. Hipwell Male
Date of Death Age If Veteran of U.S. Armed Forces,
irit 10/26/2012 90 years War or Dates 1942-1945
Place of Death Hospital, institution or
Town or j Glenyige . Street Address Ienelal _h Home
Cl
Manner of Death Q Natural Cause l Accident Homicide Q Suicide Q Undetermined fl Pending
N ilkfia Circumstances Investigation
mg Medical Certifier Name T .�,,.,.... Title,
J ng..toten_C.h e_tL M.D .
Address
7 Culligan Dr., Scotia, NY 12302
Death Certificate Filed District Number Register Number
Town or tidy Glenville 401 1.18 _ _ J
lil El Burial Date Cemetery or Crematory
QEntombment 10/25/2012 Pine View Crematorium
Address
Jiii Cremation Queensbury, N Y .
Date Place Removed
Removal and/or Held
and/or
Address
Hold _:. ,.
Date Point of
tit Ei Transportation Shipment
by Common Destination
Carrier
,,: Date — Cemetery Address
i ii 11 Disinterment
d Date Cemetery Address
Reinterment
'' Registration Number
w Permit Issuedta Name of Funeral Home Regan penny Stafford Funeral Home 01443
10 Address
53 Quaker Road, Queensbury, Ny 12804 _
Name of Funeral Firm Making Disposition or to Whom
.,..,: Remains are Shipped, If Other than Above __.__ ._.__-. .
Address
MI-
,,i .,..
M I-
,,i Pal-Mission is hereby granted to dispose of the human remain d cribed abovi as i caw .
i Date Issued 10/29/2012 Registrar of Vital Statistics ,' /
Vg, (signat -
kh,l
0:.
,n D .District Placect Number 4651 Glenville
:, is-
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
Place of Disposition 'tD t i � or,t _
lit Date of Disposition io �;t�►� _ i
p (address)
(section) ` (lot number) (grove number)
Name of Sexton or Person in Charge Premises ryrr ""
plea.,e print)
W ignature —z, Title f2i'Mff>-d
•
(over)
;DOH-1555 (02/2004) •