Robichaud, Donald 4 3GINEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
me.
Name First Middle Last Sex
:.f 1 Donald J. Robichaud Male
Date of Death Age If Veteran of U.S. Armed Forces,
me
June 4, 2014 79 War or Dates ,re_ l
iPlace of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
ii Manner of Death X Natural Cause Accident I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Carr-t 2, m.,r0 c� -
Address
.v„. Death Certificate Filed Di t�umbe Register Number
ve City, Town or Village Fort Edward,NY J 75 41
'. ❑Burial Date Cemetery or Crematory
June 6, 2014 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
'r:: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a
tPermission is h re y g anted to dispose of the human alns described abo e as indicated.
Date Issue 5 / Registrar of Vital Statistic 0� pp
r (signature)
YJ
• District Number 5753 Place Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of in ac
cordance with this permit on:
WDate of Disposition (D AVM Place of Disposition U40.4 1 oc,v-
W (address)
Cl)
0 (section) (lot number) (grave number)
QName of Sexton or Person in harge of Premises 3s i*
Z (pl ase print)
W �,�/
Signature fL,s.. Title L 4�"
(over)
DOH-1555(02/2004)