Davis, Robert k li . bbU
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Robert Lee Davis Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/06/2013 67 years War or Dates
Place of Death Hospital, Institution or
W City, TomtR iII� XX ( lens Falls Street Address Glens Falls Hospital
• Manner of Death Km, Cause Accident 0 Homicide Suicide Undetermined Pending
III Circumstances Investigation
la Medical Certifier Name Title
Q. Daniel Way M. D.
Address
North Creek Health Center North Creek, N Y 12853
Death Certificate Filed District Number Register Number
City, Tow XillkX XX Glens Falls 5601 468
DBurial Date Cemetery or Crematory
❑Entombment 11/08/2013 Pine View Crematorium
Address
.:.:,,i1:51gr.emation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton- Mc Dermott Funeral Home, Inc. 00141
Address
9 Pine Street Chestertown, N Y 12817 _
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr.
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/08/2013 Registrar of Vital Statistics L )c'LA,yc"yam, W YtA 3t
(signatur
District Number Place
5501 Glens Falls
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tia• Date of Disposition Ij/Z-l.3 Place of Disposition i?rv.c v ,pc..,,
t, , 7
(address) '
LU
tfl
CC (section) / (lot number) (grave number)
O Name of Sexton or,Verson in C of Premises 2 4./,�-,
II
�% (please print)
Signature 10 A' Title 17 2 A-7 .
(over)
DOH-1555 (02/2004)