Jacobs, Robert 15 -- i 53
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
4:; Robert Jacobs Male
. e� Date of Death Age If Veteran of U.S. Armed Forces,
• March 5, 2014 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Ft. Hudson Nursing Center
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
1 Medical Certifier Name Title
Daniel Larson
Address
• 9 Carey Road,Queeensbury,NY 12804
:. Death Certificate Filed District Number Register Number
▪ City, Town or Village Fort Edward,NY 5755 c.o
❑Burial Date Cemetery or Crematory
El Entombment March 6, 2014 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
0 Date Point of
NI 1 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
Kti
Permission is hereby granted to dispose of the huma ins described
above as indicated.
Date Issued ( 014 Registrar of Vital Statistics ' OCUA.,9c-----,
(signature)
District Number 5755 Place Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3jti fiq Place of Disposition gvliit�,,,j Cfthciaria—`
2 (address)
W
Cl)
p0 (section) //�� (lot number) (grave number)
Name of Sexton or Person in Charge f Premises /hrif- .�t
Z V(please print)
Signature Title CP.111,Z.
(over)
DOH-1555(02/2004)