Charbonneau, Robert � . / 530
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Charbonneau Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 16,2015 62 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
in Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ttl Circumstances Investigation
Medical Certifier Name Title
J. Stratton Dr.
Address
14 Manor Dr.,Queensbury,NY 12804
'4° : Death Certificate Filed District Number Register Number
_::: City, Town or Village Glens Falls, NY 5601 3 Li8-
❑Burial Date Cemetery or Crematory
July 21, 2015 Pine View Crematory
Entombment Address
El Cremation Quaker Road, Glens Falls,NY 12804
Date Place Removed
Z Removal and/or Held
pg and/or Address
I— Hold
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0 Date Point of
NTransportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:i 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
` Address
,113
LPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued '2/ t `1 I IS Registrar of Vital Statistics L ) CA.Ai "Q. ./t-
(signa
District Number E 6 c3 v Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 70.31lr Place of Disposition ��U..../ C
2 (address)
W
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0 (section) (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises IL,f L Sf-Ati-
Z (pl ase print)
W
Signature G'� Title (Q"1 lint,f(_
(over)
DOH-1555(02/2004)