Archambault, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
s - Name First Middle Last Sex
i> Robert Edward Archambault Male
Date of Death Age If Veteran of U.S. Armed Forces,
r October 12, 2014 77 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide El Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
v
Tracy A. Hebert-Snell, ra�Nre/L
Address
83 Meeting House Road Schaghticoke, NY 12154
Death Certificate Filed District Number S� 7 Register Number /'
Ci , Town or Villa e 1p
51
'n❑Burial Date Cemetery or Crematory
October 16, 2014 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
�, ill Disinterment
Date Cemetery Address
Ill Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
• Address
!i 82 Broadway, Fort Edward NY 12828
I if 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 de cr above as indicated.� _
Date Issued t o j ►51 It( Registrar of Vital Statistics ..'O.
(signature)
• District Number 5 1 511 Place j4-u-erg -ci►, k jj I 2_F'-3 y
k<-::
yr I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 10/16/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /�` (lot number) (grave number)
Name of Sexton or Person in Char a of Premises ( ''� 5`i
rd
please print)
Signature `''lk. Title Cktfl
(over)
DOH-1555 (02/2004)