Brooks, Robert .goo
NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section Burial _ Transit Permit
Name First
x�r; Middle Last Sex
✓ Robert Francis Brooks Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 3, 2015 83 War or Dates Korean
Place of Death Hospital, Institution or
City, Town or Village Queensbury, NY Street Address 71 Longview Drive Apt 273
fgManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
�3 Circumstances Investigation
Medical Certifier Name Title
..▪.. Patricia Auer,PA
:44-
Address
ex-
e.:::.: Queensbury,NY
eve Death Certificate Filed District Number Register Number
Cit1`fown or Village Queensbury, NY 5657 {'1;
❑Burial Date Cemetery or Crematory
November 5, 2015 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
N
0 Date Point of
NTransportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
gAddress
Permission is hereby granted to dispose of the human r Ain d . ibe, •b• e as indicated.
Date Issued l_� ,� �j� Registrar of Vital Statistics ` t Nor �„
40L6-4
(signature)
District Number 5(a5� Placet
H I certify that the remains of the decedent identified abo were disposed of' acco ance with this permit on:
Z
Lu Date of Disposition 1//r,/if Place of Disposition ,pa i,., AleIacw..
W (address)
U)
pCC (section) (lot number (grave number)
Name of Sexton or Person in Charge of Premises �s�- ��number (grave
(please print)
W Signature �� Title "'fOnl
(over)
DOH-1555(02/2004)