Sesselman, Robert NEW YORK STATE DEPARTMENT OF HEALTH
A tick.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Sesselman Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 5, 2013 69 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Indian Lake Street Address 1023 Cedar River Rd
Lit
n Manner of Death Natural Cause Accident Homicide Suicide n Undetermined n Pending
W Circumstances Investigation
W Medical Certifier Name Title
Cl. T. Coppens 9
Address
`' ,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Indian Lake Indian Lake Zd S 3 a
❑Burial Date Cemetery or Crematory
❑Entombment Address
❑Cremation _
Date Place Removed
ZZ Removal and/or Held
• and/or Address
E Hold
Cl) -
O Date Point of
N ❑Transportation Shipment
'p 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
Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
2 Address
.0
US
•a
<: Permission is here granted to dispose of the human emai s described/ ve as indicated.
Date Issued `Z . Registrar of Vital Statistics /1 Q� ( [ _
(signature)
District Number (a:53 Place Indian Lake
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition C I51 t3 Place of Disposition Y+r )t.� C;rvrnti4 or,u'.-
$ (address)
W
re (section) lot number) ,�1 (grave number)
00 Name of Sexton or Person 'n Charge of Pr ises f , �nr�`'
Z (phase print)
W Signature Title Ci?'IhAtl,
(over)
DOH-1555(02/2004)