Lockwood, Robert NEW YORK STATE DEPARTMENT OF HEALTH rip „3 ff Zr
Vital Records Section Burial - Transit ermit
-, Name First Middle Last Sex
Robert Lockwood Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 12, 2013 91 War or Dates
Place of Death Hospital, Institution or
• City, Town or Village South Glens Falls Street Address 184 Main Street
Manner of Death El Natural Cause 0 Accident 0 Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,
OA
Address
it 161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
A_ City, Town or Village South Glens Falls
❑Burial Date Cemetery or Crematory
May 14, 2013 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
a Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
_VkEl Reinterment Date Cemetery Address
-:-APermit Issued to Registration Number
gip
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
z Remains are Shipped, If Other than Above
Address
Permission is hgreb granted to dispose of the human re i described ve as 'ndicat
Date Issued 5//f//3 Registrar of Vital Statistics
signature)
e District Number 1.4 Place ale 5 , 501,0/4 6/a/2.5 kiis
_:-,.„.
A I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
° Date of Disposition 05/14/2013 Place of Disposition Quaker Road Queensbury,NY 12804
v (address)
t `h/(section) /,�j F (lot numbe (grave number)
Name of Sexton or Perso in Charge of Premises r�,ty�-r th rf/f
+(please pant)
Signature L. Title C j0
(over)
DOH-1555 (02/2004)