Hazelton, Robert t COL
NEW YORK STATE DEPARTMENT OF HEALTH'- . 4 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Haz.elton Male
Date of Death Age If Veteran of U.S. Armed Forces,
'><< 1 1 /30/201 2 66 War or Dates
No
Place of Death Hospital, Institution or
til
t8itiActimanxarVillage Hoosick Falls StreetAddresscpntpr fnr Nursing & 'Rehab
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide rl Undetermined ri Pen ci ing
Circumstances Investigation
JAI Medical Certifier Name Title
CI Peter Peff M.D.
Address
35 Gilbert St. , Cambridge, NY 12816
Death Certificate Filed District Number Register Number
a pF rx /iilage Hoosick Falls 1 :p y
gii ❑Burial Date Cemetery or rematory
1 2/0 4/2 01 2 Pine View Crematorium
.:::::::i❑Entombment Address
®Cremation Quaker Rd. , Queensbury, NY
:im Date Place Removed
gRemoval and/or Held
and/or Address
to
Hold
Date Point of
0 Transportation Shipment
.d by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Carlton Funeral Home Inc.
Registration Number
Name of Funeral Home 68 Main St, PO Box 67, HUdson Falls,NY 00281
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
LU
Permission is hereby granted to dispose of the human remains described abo as indicated.
Date Issued
1 2/3/2 01 2 Registrar of Vital Statistics � \1k-_. M, ��s Q�
signature)
District Number ,t `iv) Place Hoosick Falls Village Clerk •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
C
t Date of Disposition 1Z t M hi, Place of Disposition �? kP,,�
(address)
iii
tr (section) (lot number) (grave number)
2 Name of Sexton or Person in Charge f Premises n ... 6141+
2 (pi ase print)
Ail"—l"-- Title CPgitf�}
(over)
DOH-1555 (02/2004)