Pendas, Robert 4-(I2NEW YORK STATE DEPARTMENT 0;- LIEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
4 Robert W. Pendas Male
Date of Death Age If Veteran of U.S. Armed Forces,
ip February 14, 2014 81 War or Dates Korean
Place of Death
Manner of Death F.-1,
W. Circumstances Hospital, Institution or
City, Town or Village Queensbury Street Address 11 Bronk Drive
Natural Cause r7 Accident El Homicide Suicide ri Undetermined Pending
Investigation
Medical Certifier Name Title
Christopher ag D.Hoy Dr. _
Address
AS 161 Carey Road,Queensbury,NY 12804
m Death Certificate Filed District Number Plegister Number
City, Town or Village Queensbury 5657 i Co
0 Burial Date Cemetery or Crematory
0
February 20, 2014 Pine View Crematorium
Entombment
Address
El Cremation 21 Quaker Road,Queensbury, NY 12804
Date Place Removed
z ri Removal and/or Held
0 'and/or Address
E Hold
Cl)
0 Date Point of
fits pi Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
E Reinterment
Date CemeteryAddress
IN Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
• Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human e ains described abo eras indicated.
Date Issue ) (5d 801L-1 Registrar of Vital Statistics
(signature)
District Number 5657 Place Queensbury
0.:.,
i_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
11J Date of Disposition QiiVIN Place of Disposition C..a. kkj (ft:Lit 6..-
2 (address
ILI
CO
W
0 (section) ,(lot number) (grave number)
a Name of Sexton or Pers n in Charge of Premises co 1.1t.- ,. .....4--
Z (plefase print)
U.I
Signature cot
T Title ClZfAl t6PC
(over)
DOH-1555(02/2004)