Wood, Robert NEW YORK STATE DEPARTMENT OF HEALTH `` ; # aq f
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert John Wood Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 2, 2014 54 War or Dates
I-- Place of Death Hospital, Institution or
. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Lit Manner of Death❑ Natural Cause ❑ Accident ElHomicide 0 Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number RegisterNumber
, ? City, Town or Village 5601
fit❑Burial Date Cemetery or Crematory
April 4, 2014 Pine View Crematorium
-'1 ❑Entombment Address
�.`®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z- ❑ Removal and/or Held
and/or Address
Hold
Date Point of
c El Transportation Shipment
by Common Destination
C3 Carrier
' Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
- Permit Issued to Registration Number
_ Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
`�",,, Address
Cr
Permission is hereby ranted to dispose of the human remains describ b e2 ind'
` Date Issued -p ` �! Registrar of Vital Statistics e .
(signature)
District Number 5601 Place
-F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 04/04/2014 Place of Disposition Quaker Road Queensbury,NY 12804
M (address)
LIJ}
° ,
Z. (section) lot number) (grave number)
Gil Name of Sexton or Perso in Charge of Premises r. �- Li�-
Z' (ple se print)
Signature -- Title riVitiffae
(over)
DOH-1555 (02/2004)