Copeland Sr, Robert NEW YORK STATE DEPARTMENT OF HEALTH
11 ti6,7
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Robert D Copeland Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/19/2014 93 years War or Dates 1938-1971
Place of Death Hospital, Institution or
City, Toww) j'il) XX Glens Falls Street Address Park St Glens Falls, N Y 12801
ILIWa Manner of Death vItural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
{� Circumstances Investigation
W Medical Certifier Name Title
Z4. Shahid Ahmed Physician
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TowNXIOMOXIXXX Glens Falls 5601 351
❑Burial Date Cemetery or Crematory
❑Entombment 07/21/2014 Pine View Cemetery
Address
tilC,remation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
F= Hold
CA
0 Date Point of
in❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
it
11
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/21/2014 Registrar of Vital Statistics 0,.) c 4,,\sk 11J
(sig-1 nature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1 Date of Disposition 1 �Z{i/� Place of Disposition gt....J L µ,701.-.,
(address)
LEI
1.
CC (section) (lot n ber)- c (grave number)
DName of Sexton or Person in Charge of Premises /7,,,Iir_ +wil-
i (please prin
Signature Title CIig,M
(over)
DOH-1555 (02/2004)