Metthe, Robert j_ -vim
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Lastat.
e �.& Sex
Robert H ` IMale
>i Date of Death Age If Veteran of U.S. Armed Forces,
05/22/2013 92 years War or Dates 1944 -45
1 Place of Death Hospital, Institution or
City, Tow it Street Address •
rj Manner o ea h Natural Cause Accident Homicide 0 Suicide Undetermined Pending
t4 Circumstances Investigation
U.
uj Medical Certifier Name Title
0 Graham Atkins JV1 D
.Address
101 Carey Rd Queensbury, N Y 12804
Death Certificate Filed District Number Register Number
City, TowgC ill XX GtensFaits 5801 223
;~❑Burial Date Cemetery or Crematory
❑Entombment Address 05/21/2012 Pine View Crematorium
::❑C!pmation Qu enshu T NY 12804
Date Place Removed
Removal and/or Held
..R and/or Address
Hold
{
- 0 Date Point of
Q Transportation Shipment
L by Common Destination
Carrier
j Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ip Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schrnon I ake, N Y 870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;, _ Address
fii
Permission is hereby granted to dispose of the human remains described above as indicated.
<; Date Issued 05/23/2013 Registrar of Vital Statistics t/)C&. Q "tio
(signature)
District Number Place
Mli 5601 Glans Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition 5=-0D/j Place of Disposition dit/Z._
eigate,f,eticir-/
(address)
ta
to
#c (section)5 (lot umber
. ) (grave number)
its Name of Sexton or rso in a of Premises lii.J/A71
Jesse p/r�t)
,::::!:;:i Signature Title
(over)
DOH-1555 (02/2004)