Fichtner, Robert NEW YORK STATE DEPARTMENT OF HEALTH { 6a3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
- Robert R. Fichtner Male
Date of Death Age If Veteran of U.S. Armed Forces,
111 August 13, 2015 71 War or Dates
-.e Place of Death Hospital, Institution or
_ City, Town or Village Glens Falls Street Address - Glens Falls Hospital
` Manner of Death X❑ Natural Cause ❑ Accident ❑Homicide 0 Suicide n Undetermined ❑ Pending
Medical Certifier Name
�Z I Circumstances Investigation
Sean Bain, M.D. of.
3Y Address �;,,
100 Park Street -ails, NY 12801
Death Certificate Filed District Number lkJ l Register Jjl r
; City, Town or Village Glens Falls
lt❑Burial Date Cemetery or Crematory
August 18, 2015 Pine View Crematory
-,❑Entombment Address
3p3E1 Cremation Quaker Road Queensbu, 7 12804
❑
and/or Removal Date Place Removed
and/or Held
Hold Address
.
= Date Point of
. -r❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
❑ Renterment Date Cemetery Address
'. Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
44 136 Main Street, South Glens Falls NY 12803
*32
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
f Address
- ,:
Permission is he eby granted to dispose of the human remains scribed bove as ndic. ed.
Date Issued CD'3 15 Ls Registrar of Vital Statistics (17p p� G
r , (signature)
District Number SAC)/ Place _ jil„- /qL-�' - i'
certify that the remains of the decedent identified above were disposed of in accorda a with this permit on:
Date of Disposition 08/18/2015 Place of Disposition Quaker Road Queensbury,NY 12804
t _ (address)
1t
(section) 10t number) (grave number)
' Name of Sexton or Person i Charge of Premises S;444-
(p/ ase print)
SignatureTitle C>t.MNg
g /I—
(over)
DOH-1555 (02/2004)