Cavanaugh, Robert NEW YORK STATE DEPARTMENT OF HEALTH :t
Vital Records Section Burial - Transit Permit
Name First Middle n Last Sex
Robert D- Cavanaugh Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 27, 2015 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Street Address Glens Falls Hospital
ig Manner of Death k Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Matthew Varughese
Address
100 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number F n' Register Number
City, Town or Village ��� 520
❑Burial Date Cemetery or Crematory
Ill Entombment October 28, 2015 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I j Removal and/or Held
and/or Address
H Hold
N
O Date Point of
y ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:;:; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
U. Address
g
Ai
• Permission is hereby granted to dispose of the human remains described aboo e a ' icated.
Date Issued /Q/1 0W fi Registrar of Vital Statistics 441 `
(signature)
District Number (c Q/ Place C44•4 AA,
;,::::
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition !c/z$I11s Place of Disposition AZALd Ir a
2 (address)
W
U)
Q0 (section) / (lot numbs (grave number)
Name of Sexton or PersoAn in Charge of Premises /1 r„ ,-) 1 fir
`, (please print)
W Signature fi69 Title (CVsh Q
(over)
DOH-1555(02/2004)