Fleming, Robert NEW YORK STATE DEPARTMENT OF HEALTH & 5 O
Vital Records Section Burial - Transit Permit
Name First a Middle Last Sex
Robert Earl Fleming Male
Date of Death ` Age If Veteran of U.S. Armed Forces,
September 24, 2012 68 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
£ Manner of Death J Natural Cause ID Accident El Homicide El Suicide riUndetermined 0 Pending
LU
Circumstances Investigation
W Medical Certifier Name Title
�
Michael Fuller, M.D
Address
102 Park St Glens Falls, NY 12801
Death Certificate Filed District Nurr ri O/ Register) 4rl 7
City, Town or Village J c ' �-�
❑Burial Date Cemetery or Crematory
October 1, 2012 Pine View Crematorium
Q Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
{ and/or Address
E Hold
U Date Point of
eL ❑Transportation Shipment
0) by Common Destination
C Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
F-" Remains are Shipped, If Other than Above
2 Address
W
�- Permission is hereby ranted to dispose of the human rem�iris desc ' ed above •s indica ed.
Date Issued egistrar of Vital Statistics V d „ /./ L 1J _
/ _ (sign
ure)
District Number / Place 41 ' p _,
I certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
W` Date of Disposition i0171I7„ 1Ut4iJ
Place of Disposition ' Crovciortu"_
(address)
W
c' (section) ot number), (grave number)
0
L0 Name of Sexton or Person in Charge Premises AlC4E'� e ""�µ
{/ease print)
W Title C/�c hq.�Lit
Signature ��'�`—�-
(over)
DOH-1555 (02/2004)