Gleason, Robert NEW YORK STATE DEPARTMENT OF HEALTH i♦ ��
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
-• k.
Robert Joseph Gleason Male
BO Date of Death Age If Veteran of U.S. Armed Forces,
u January 31, 2015 86 War or Dates
1 Place of Death Hospital, Institution or
W' City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause 0 Accident ❑Homicide ❑ Suicide ❑ Undetermined Pending
, Circumstances Investigation
WI Medical Certifier Name Title
a Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
, Death Certificate Filed District Number Register N mber
go- City, Town or Village 5601 S8
❑Burial Date Cemetery or Crematory
February 3, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
• Removal and/or Held
and/or Address
p Hold
0) Date Point of
Q. El Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
,N. ' Date Cemetery Address
0 Reinterment
• ' Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Zi Address
,Ix;
o, Permission is hereby granted to dispose of the human remains de ,i d,abo as . ated.
40 / f
Date Issued Q2�Q3�Z0/5"" Registrar of Vital Statistics ,
., (signature)
District Number 5601 Place 6(e//S /a(/5,/VI/ /)�'�1
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/03/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2_ " (address)
W= burial in St.
U?: FE
�+., g m (lot number) (grave number)
3 Name of Sexton or Perso in Charg of Premises CL�, Se"
^z lease print)
W= Signature Title C¢t;M i
(over)
DOH-1555 (02/2004)