Fosdick, Robert NEW YORK STATE DEPARTMENT OF HEAL.,T'H
Vital Records Section '� Burial - Transit Permit
Name First Middle Last Sex
Robert Jeffrey Fosdick Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 17,2014 64 War or Dates
Place of Death Hospital, Institution or
ii City, Town or Village Johnsburg Street Address 106 4H Road
aManner of Death [� Undetermined Pending
C�= �XI Natural Cause I I Accident n Homicide 'Suicide
WI Circumstances Investigation
Medical Certifier Name Title
a Ellen M.Duprey
4 1 Address
HHHN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 Q 5_
❑Burial Date Cemetery or Crematory
September 18, 2014 Pine View Crematory
❑Entombment Address
IJ Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
Hold
0 Date Point of
N _
Transportation Shipment
`p by Common Destination
Carrier
I I Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
`; Address
3809 Main Street,Warrensburg,NY 12885
'°' Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
b Address
tel
1t1
4) Permission is hereby granted to dispose of the human remains described ove as indicated.
:' Date Issued `"l \<- 14, Registrar of Vital Statistics L.., .b
_ (signature)
:. District Number 5655 Place Johnsburg
gym:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I--
WDate of Disposition 4Iv.j fq Place of Disposition gat-,w C'«4.4•ro
2 (address)
W
co
0 (section) (lot number- (grave number)
0 Name of Sexton or Person in Charge of Pr mises AjtAt .Jpnred
Z r (p/else print)
W it
Title Ci�F, k
Signature
(over)
DOH-1555 (02/2004)