Bacon Jr, Robert NEW YORK STATE DEPARTMENT OF HEALTH , . _ r/ q74,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert L. Bacon Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 7, 2015 66 War or Dates Vietnam
i- Place ath L Hospital, Institution or
wCity own r Village TOc I— c�WcIJ (� Street Address Residence
WManner o DeathILI Natural Cause ❑ Accident ❑Homicide 0 Suicide ❑ Undetermined Pending
i. Circumstances Investigation
W Medical Certifier Name Title
a Douglas Dennett, M.D
Address
84 Broad Street Glens Falls, NY 12801
Death • icate Filed,. District Nu r Register NAmber
City, own Village [-nr4- Ecic ) (3tSd ne��5 54
❑Burial Date Cemetery or Crematory
June 9, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
.❑ Removal and/or Held
and/or Address
=H Hold GERALD BH SOLOMON NAT
C Date Point of CEMETERY
p„ ❑Transportation Shipment
(I) by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
`;,; Date Cemetery Address
❑ 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
Address
CL Permission is hereby granted to dispose of the human ns d scrib d a e ' dicated.
Date Issued D6-0%.0aegistrar of Vital Statistics V i
�.------, (signature)
District Numbe Place /�
��� �J15� � �Ll� �t EC1�11�QVI,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
14 Date of Disposition 06/09/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W.
ir (section) (lot number)c (grave number)
Name of Sexton or Perso4n in Charge of Premises P^+f `�l' '
( lease print)
WE Signature4 Title /WfrRti
(over)
DOH-1555 (02/2004)