Capone Sr, Robert # 627
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert E. Capone,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 25,2013 44 War or Dates
Place of Death Hospital, Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause Accident El Homicide El Suicide El Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
O Timothy Murphy
Address
52 Haviland Ave,Glens Falls,NY 12801
Death Certificate Filed Glens Falls District Number Registers of
City,Town or Village 5601 L
❑Burial Date Cemetery or Crematory
August 30,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ri Removal and/or Held
• and/or Address
H Hold
N
o Date Point of
El Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
Address
W
• Permission is hereby ranted to dispose of the human re, ains d cribed a ove as indi :ted
Date Issued 0 Registrar of Vital Statistics
(signature)
District Number 1 Place Glens Falls
I certify that the remains of the decedent identified above were •isposed of in accordance with this permit on:
w Date of Disposition `1 I31 t3 Place of Disposition Zit,/
2 (address)
W
(section) /' (lot mbar) c (grave number)
Q Name of Sexton or Person in Charge of emises L Jl" 1 Jh+AN
Z (pi lase print)
W Signature /4L Title C lIehl f i QL
(over)
DOH-1555(02/2004)