Robinson, James NEW YORK STATE DEPARTMENT OF HEALTH s 11 J Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Henry Robinson Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 23, 2012 67 War or Dates
h Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
GI Manner of Death Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined ri Pending
W
U Circumstances Investigation
WW, Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
20 Murray Street Glens Falls, NY 12801
D h Certificate Filed District Number 5 r�oi Register Number
s
ity, own or Village CI r n s FaA I s 59 2—
Burial Date Cemetery or Crematory
December 27, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date ' Place Removed
z ❑ Removal and/or Held
and/or Address
H Hold
N Date Point of
dEll Transportation Shipment
(I) by Common Destination
tD Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I - Remains are Shipped, If Other than Above
2 Address
ce
U
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1242G t ( Z Registrar of Vital Statistics �0 �°��`
(signature)
District Number 56 d i Place 6 u„,/`5 1,1 S)i 7
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 12-1'6. 1 Place of Disposition ef2,140414 Lrimr,tAri.�
2 (address)
W
N Ce (section) (i t number) (grave number)
C
i Name of Sexton or Person in Charge of Premises r'��r�►'�� JQ"
rift
(please print)
III Signature � -4----- Title
CtZeP It70!'.
(over)
DOH-1555 (02/2004)