Simpson, Robert NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Gage Simpson Male
Date of Death Age If Veteran of U.S. Armed Forces,
08/11/2013 80 years War or Dates Army Air Corp.
}= Place of Death Hospital, Institution or
ZCityIli , Townj(iIXX Glens Falls Street Address Glens Falls Hospitaol
Manner of Death 1[plural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
IliCircumstances Investigation
iii Medical Certifier Name Title
t? Dean A Reali M D
Address
3767 Main Street Warrensburg, N Y 12885
Death Certificate Filed District Number Register Number
City, TowX X)(ili 0XX Glens Falls 5601 346
:. ❑Burial . Date - Cemetery or Crematory
❑Entombment 08/13/2013 Pine View Cemetery
Address
Cyemation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
- and/or Address
- Hold
I
Date Point of
❑Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address �"
South Glens Falls, NY 121,03 1� J�1"K. Au1/4j,�
Name of Funeral Firm Making Disposition or to Whom J
17 Remains are Shipped, If Other than Above
2 Address
tr
t
` Permission is hereby granted to dispose of the human remains described above asrindicated.
Ei Date Issued 08/12/2013 Registrar of Vital Statistics LJ W
( , (signature)
District Number 56n1 Place Glens Falls 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lii I R
Date of Disposition 11010�3 Place of Disposition � ilk,J (4._..
(address)
W
tO
CC (section) (lot number) (grave number)
ci Name of Sexton or Person i Charge of Pr mises ftAttyL
(please print)
Signature Title
(over)
DOH-1555 (02/2004)