Fedor, Robert NEW YORK STATE DEPARTMENT OF HEALTH. le tt Lk(1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert S. Fedor Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/07/2012 86 War or Dates World War It
Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address The Pines at Glens Falls
Manner of Death 0 Natural Cause 0 Accident El Homicide El Suicide ❑Undetermined Pending
III
Circumstances Investigation
W. Medical Certifier Name /2 Title/f
C, U /?f'r - /9 J1 U ',ff5 / i 7Z
/7e) kh,,,frei-7 , •/ - /,-----/i,e--Address /4 .1 Y ,101 Pa Z
•-L Certificate Filed �/ District Number_ Register N ber
Iv ,Town or Village ( f tr LSS 0 Q
❑Burial Date or Crematgry, I'�
12/10/2012 /h-� f/l-e C / 6.re,//y/ `-ii
❑Entombment Address
®Cremation ( G/k‘rer , ' 6?"-'"e1Cr iefl7 d7
�71
Date Place Removed
z El Removal and/or Held
and/or Address
E, Hold
0. Date Point of
a0 Transportation Shipment
by Common Destination
CI' Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
Address
W
0. Permission is here y ranted to dispose of the human remains descries• a•ov as" ' ated.
Date Issued /2. /0 20/2_ Registrar of Vital Statistics /'-'
f s x2/ (signature)
District Number jC/ Place 6' /dP07
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12-li-tt Place of Disposition ZOti,..) C dr w*.-
2; (address)
Ul
C (section) it
- (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises A"NPLs' � 1Offli*
Z.t (please print)
W' Signature L' "— �.— Title cJEvn►t-cet,
(over)
DOH-1555(02/2004)