Havens, Robert NEW YORK STATE DEPARTMENT OF HEALTH" ' 1 5 q
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Joseph Havens Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/27/7013 92 years War or Dates W W I I
Place of Death Hospital, Institution or
IliCity, Tovtr VRA Glens Falls Street Address Park St Glens Falls, N Y 12801
Manner of Death QNatural Cause 0 Accident 0 Homicide ❑Suicide ri Undetermined ri Pending
Circumstances Investigation
fa
la Medical Certifier Name Title
41 Frances C Bollinger M n
Address
100 Broad Street Glens Falls, NY 12801
ni Death Certificate Filed District Number Register Number
City, ToMeitrXVikificx (;Ions Falls 5A01 130
MI❑Burial Date Cemetery or Crematory
❑Entombment 04/01/9013 Pine View Cemetery
Address
"` ❑C, remation Queensbury, NY 12804
_Data_ Place Removed
Removal and/or Held
LI and/or Address
ti
Hold
{? Date Point of
0 Li Transportation Shipment
0 by Common Destination
Carrier
`! ❑Disinterment Date Cemetery Address
`Q Reinterment Date Cemetery Address
Permit Issued to' Registration Number
iligi Name of Funeral Home Maynard D. Baker Funeral Home 01130
<s Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01.i28i 0; Registrar of Vital Statistics V CLA t./0111:ter
(signature)
iia District Number Place `T
5601 Glans Falls ; f� 1)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 c� 7.5
l Date of Disposition -t'2: 3 Place of Disposition e0`1,► C?'GMC10(11ei
(address)
tii
CA
l (section) (lot numbe (grave number)
Name of Sexton or Person in Charge of Premises fin AWL— r'►•40t/4"
�g (please print)
14
Signature.- Title CCMflt,
(over)
DOH-1555 (02/2004)