Rich, Robert NEW YORK STATE DEPARTMENT OF HEAL -I 1 ` ' c—O
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Robert Charles Rich Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 23, 2013 65 War or Dates
Place of Death Hospital, Institution or
al City, Town or Village Queensbury / Street Address Apt 6, 205 Robert Gardens North
Ci Manner of Death 0 Natural Cause ❑ Accident n Homicide n Suicide n Undetermined C Pending
tj Circumstances Investigation
. Medical Certifier Name Title
CI
Address
Deat -•. icate Filed r. DEict N mber R gl tgr'Number
City, own .r Village `,�0,s Gc,— LcS r v`-1
0 Burial Date ( Cemetery or Crematory
August 26, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Z ❑ Removal and/or Held
,0 and/or Address
. Hold
V) Date Point of
ETransportation Shipment
(0 by Common Destination
El Carrier
-„ Disinterment Date Cemetery Address
Date Cemetery Address
I I Reinterment
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
,. Address
W''
I' Permission is ,hereby granted to dispose of the human r ins described�above as indicated.
Date Issued 1& '�C)1Registrar of Vital Statistics ! — 0 , �.J
_ (signature)
District Number( 1 Place n ci a.c C1.k_sts2.,,^S)
• I certify that the remains of the decedent identified above were disposed of in accorda e with t is permit on:
L' Date of Disposition '' // 0 y
W p ���-f� Place of Disposition p N�, tsi�t.�✓ ll�i,?�9-
(address)
Ltd;
i (section) /' f�(lot nu ber) (grave number)
• Name of Sexton Per n i arge of Premises spa // J •^,/iA►z S
z (please print)
LU Signature Title c 21.4 41
(over)
DOH-1555 (02/2004)