Austin, Robert NEW YORK STATE DEPARTMENT OF HEALTH 43
Vital Records Section Burial - Transit Permit
Name First Middle 4 Last Sex
Robert F. Austin Male
Date of Death Age If Veteran of U.S.Armed Forces,
i. March 23, 2015 74 War or Dates 1958-1961
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
•
G Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑Suicide n Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Gamal Khalifa MD
Q Address
102 Park Street Glens Falls New York 12801 Glens Falls Hospital
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
March 27, 2015 Pineview Crematorium
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
and/or Address
I' Hold
0 Date Point of
1.1 ❑Transportation Shipment
d by Common Destination
Carrier
- Date Cemetery Address
a ❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3) 261 i5 Registrar of Vital Statistics GA7
CA' "/ ` (signature)
District Number 5 60 1 Place Glens Falls,New York
I- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition ?' 7-fr Place of Disposition Pineview Crematorium
2 (address)
N
0 0 (section) 4nurrler) (grave number)
Name of Sexton or P i arge of Premises > j�/e`� ase pant) J
W Signature Title c � ,/ -
(over)
DOH-1555 (02/2004)