Russell, Robert NEW YORK STATE DEPARTMENT OF HEALTH * T1 741
Vital Records Section Burial - Transit Permit
:
ee Name First Middle Last Sex
r:
:r Robert Douglas Russell Male
;::;:: Date of Death Age If Veteran of U.S. Armed Forces,
April 13,2014 89 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
gi Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.121 Roslyn Socolof
:1 Address
Westmount Health Facility,Queensbury,NY 12804
: : Death Certificate Filed District Number e is er Number
_::: City, Town or Village Queensbury 5657
. ❑Burial Date Cemetery or Crematory
El Entombment April 15, 2014 Pine View Crematory
Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F" Hold
CO
0 Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: s Permit Issued to Registration Number
':;:' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
:g. 53 Quaker Road, Queensbury,NY 12804
;::: Name of Funeral Firm Making Disposition or to Whom
t4 Remains are Shipped, If Other than Above
Address
ig
. ;: Permission isis hereby granted to dispose of the human r mains described above as indicated.
Date Issued 9 f( l !AC-jilt Registrar of Vital Statistics G� , a 8 A.A___`
(signature)
f District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ,'
W Date of Disposition LOON Place of Disposition NV,,, 'm-Eb4?.,
2 address)
W
CO
Ce (section) i (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises ` C, J@nnt
`Z •9 (please print)
Signature 4 „to-- Title t^
(over)
DOH-1555(02/2004)