Robbins, Henry NEW YORK STATE DEPARTMENT OF HEALTH it
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Henry Louis Robbins Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 26, 2014 77 War or Dates After 1/31/55
Place of Death Hospital, Institution or
ui City, Town or Village Fort Edward Street Address 615 Lower Oak Street
W Manner of Death u Natural Cause El Accident I I Homicide ❑ Suicide ❑ Undetermined ❑ Pending
#.? Circumstances Investigation
W Medical Certifier Name Title W,
Scott Munro, MD,
Address
Glens Falls, NY 12801
Death Certificate Filed �) ) District Number Register Number
City, o n i r Village 'Gc/wCm7
0 Burial Date Cemetery or Crematory
January 30, 2014 Pine View Crematorium
, : ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0, and/or Address
E Hold_
CO Date Point of
Transportation Shipment
by Common Destination
f Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I--, Remains are Shipped, If Other than Above
2 Address
ce
, Permission is ereby ranted to dispose of the humanke a' s der abov arind' ed.
Date Issued 1 Lifegistrar of Vital Statistics V-� a,
(signatu
District Number Si 55 Place I C ;�lu "
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 01/30/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W Ashes in
CO
re CAmpitch (lot number) (grave number)
0_ Name of Sexton or Person i Charge of Premises dr)-114:61. JPndti
(please print)
L1J Signature Title (koir-We
(over)
DOH-1555 (02/2004)