Beckerle Jr, Robert 71ee-v
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
;i�r; Robert F. Beckerle,Jr. Male
r :: Date of Death Age If Veteran of U.S. Armed Forces,
:: March 28,2014 65 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
M• anner of Death X Natural Cause 1 I Accident { I Homicide Suicide Undetermined -1 Pending
t ; Circumstances Investigation
M• edical Certifier Name Title
P, Donald Merrihew,MD
a Address
r319 Bay Road,Queensbury,NY 12804
;�- Death Certificate Filed District Number Register ,(umber
:: City, Town or Village Glens Falls,NY 5601 /t?
El Burial Date Cemetery or Crematory
March 31, 2014 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I j Removal and/or Held
and/or Address
t: Hold
co
O Date Point of
U.
I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
—
Reinterment Date Cemetery Address
f.. Permit Issued to Registration Number
ra Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury, NY 12804
�g`:.: Name of Funeral Firm Making Disposition or to Whom
iM Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains de cribe a ve .sif •icated.
.�.:;: Date Issued 03�3i/Zc?f`( Registrar of Vital Statistics /y ,.
�' (signature)
• District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition c ') Place of Disposition fç.j C.. \/4- i/ epe-1_441 4
$ (address)
W
(section) �^ // (1 number ! (grave number)
Q Name of Sexton Person ' arge of Premises J 477- It%0 4r) d
Z (please print)
Ill
Signature f Title � 1 �flik_ /S
(over)
DOH-1555(02/2004)