Folley, Robert `t z3
NEW YORK STAF E DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
__. Name First Middle Last Sex
Robert Fisk Folley Male
Date of Death Age If Veteran of U.S. Armed Forces,
7 2 76years War or Dates Us Navy
1- Place/of/Death Hospital, Institution or
1 City, Tgy+{,yq� Schenectad Street Address Ellis Hospital
0 Manner`o'�'D`eat E J Natural Cause U Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Mt �-,Y Circumstances Investigation
O.
ill Medical Certifier Name Title
Cl Alec B Platt M D
Address
124 Rosa Rd, Schenectady, N Y 12308
Death Certificate Filed District Number Register Number
City, Tom'4lX Schenectady 4601 1143
❑Burial Date Cemetery or Crematory
❑Entombment 12/29/2015 Pineview Crematorium
Address
Elpremation Queensbury, N Y i 24041 .
Date Place Removed
Z Removal and/or Held
9— �and/or Address
t Hold
N
0 Date Point of
CL
❑Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Pei mit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd, Queensbury, N Y 12804
li Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
W.
Permission is hereby granted to dispose of the human remains descri' ,• a- •ve 'n ated.
Date Issued 12/28/2015 Registrar of Vital Statistics '' /
(signature)
District Number 4601 Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ti Date of Disposition 1Z-Z943 Place of Disposition Pi et1,'se..,,) Crer„1t..y
2 (address
lAi
CC (section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
t.1:4 rr ‘u.mGcLc
zF (please print)
t Signature Title C/e d'-
(over)
DOH-1555 (02/2004)