Bates, Robert 4110
NEW YORK STATE DEPARTMENT OF HEALTH -. •
Vital Records Section Burial - Transit Permit
:;r; Name First Middle Last Sex
Robert Bates Male
Date of Death Age If Veteran of U.S. Armed Forces,
f:
i. September 12, 2014
80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville, Street Address The Orchard Nursing Centre, Inc.
g Manner of Death VI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
tg Medical Certifier Name Title
er�ri, i <.� MD
Address
\C A_ � Q. �
W 1 �,I IQ �<
Death Certificate Filed District Number Register Number
iii:*
City, Town or Village Town of Granville S7So 40
❑Burial Date Cemetery or Crematory
September 16, 2014 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
coTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
:'r 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 remains described above as indicated.
Date Issued o y')slao ly Registrar of Vital Statistics b
(sign ture)
District Number 5"756 Place Town of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q I ilk Place of Disposition fmlio.... CIA" I—,
2 (address)
W
N
tY (section) it(lot number (grave number)
ap Name of Sexton or Person in Charge of Premises 44rs,t.
Z , (please print)
W G�Signature l.f Title C4L;4t hen—
(over)
DOH-1555(02/2004)