Patchett, Robert NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex
Robert Nelson Patchett Male
[.' Date of Death Age If Veteran of U.S. Armed Forces,
March 27, 2013 86 yrs_ War or Dates W.W. II
; Place of Death Town of Hospital. Institution or
Z City, Town or Village Hague Street Address 9115 Lakeshore Drive
1"0. Manner of Death 0 Natural Cause Ej Accident El Homicide ❑Suicide El Undetermined Pending
JAI Circumstances Investigation
lijMedical Certifier Name i i f Title r
lAI= LC L'/ L��,� I
Address // ) t/
_TRv:✓ 64 i-� (C TE ' , (�L�A•/s 1ALC S A 7 I� �'�(
Death Certificate Filed Town of District Number Register Number
:g City, Town or Village Hague 5653 1
Date Cemetery or Crematory
❑Burial 3/29/2013 Pine View Crematory
Address
Cremation Queensbury, New York
Date Place Removed
0 Removal and/or Held
F and/or Address
N Hold
0 Date I Point of
ti Q Transportation j •
Shipment
B by Common Destination •
Carrier
-:•:- ___, '
:::: Disinterment Date ' Cemetery Address •
Reinterment Date I Cemetery Address •
Permit Issued to Registration Number
Mir Name of Funeral Home Wilcox & Regan funeral home • 01 821
giil -Address
- 11 Algonkin St. , Ticonderoga, NY 12883
i;- Name of Funeral Firm Making Disposition or to Whom .
1-"" Remains are Shipped, If Other than Above
Address
w .
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/2 9/201 3 Registrar of Vital Statistics ,r �� nYl �1 ►
(signs re) (�
gi District Numberl.r k Place Town of Hague �J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 4-i-3 Place of Disposition 240414 rrvrc#rif'vti
2 (address)
iUJ
N
CC (section) tJ - (1 t number- (grave number)
GName of Sexton or Person in Charge of Premises r,s- i,tr+}l
Z (please print)
Signature Title C1XlvA tA,
DOH-1555 (10/89) p. 1 of 2 VS-61