Hafner, Robert 41-
NEW YORK STATE DEPARTMENT OF HEALTH 5 7
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Robert D. Hafner ; Male
Date of Death Age I If Veteran of U.S. Armed Forces,
_January 27, 2012 I 86 War or Dates No
1... Place of Death Hospital, Institution or
Z City, Town or Village Argyle j Street Address Pleasant Valley Infirmary
QManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
0 B.Rubenstein Dr.
Address
,Cambridge,NY 12816
Death Certificate Filed District Numbers�`� i Register Number
City, Town or Village Argyle
❑Burial Date Cemetery or Crematory
January 30, 2012 j Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
1-7and/or Address
COHold
O Date Point of
O. Transportation ! Shipment
p by Common Destination
Carrier
I Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan& Potter 01646
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
CL
W _
O
Permission is hereby granted to dispose of the human r ins describ d bove as indicated.
Date Issued i JcL1 i ID. Registrar of Vital Statistics
(signature)
District Number 5c)JV Place Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— ((��
WDate of Disposition (/3o Place of Disposition i',u Ucw 64,-Ior,v1
W (address)
CO
O (section) A _ (lot number) r` (grave number)
pName of Sexton or Person in Charge of Premises `/ r,ittfli— J 0% 44
W (please print)
iL
Signature Title C MRTot
(over)
DOH-1555(02/2004)