Robetor, Clifford NEW YORK STATE DEPARTMENT OF HEALTH /1-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clifford A. Robetor Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. December 1, 2014 60 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Residence
o Manner of Death ❑ Natural Cause ❑ Accident ❑ Homicide ❑Suicide n Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
Mrs. Ruth Scribner Coroner
Address
Whitehall, NY 12887
Death Certificate Filed District Number Register Number
r
City,Town or Village Whitehall / 1
n Burial Date Cemetery or Crematory
December 3, 2014 Pineview Crematorium
❑Entombment Address
Z n Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
and/or Address
Hold
Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
n Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
2 Name of Funeral Firm Making Disposition or to Whom
ix Remains are Shipped, If Other than Above
W Address
0
Permission is hereby granted to dispose of the human remains_described above as indicated.
Date Issued (� /{ Registrar of Vital Statistics .{1. . tt,°(,. ia:
(signature)
District Number 5701g Place Whitehall,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 12/03/2014 Place of Disposition Pineview Crematorium
W (address)
Ce
rn
(section) (Ipt number) r (grave number)
O Name of Sexton or Person in Charge of Premises t L,,,t)� 3 t.wit
_ (please print)
Signature ( �.� Title COE MOM.
(over)
DOH-1555 (02/2004)