Addison, Robert NEW YORK STATE DEPARTMENT OF HEALTH i ./I ) )
Vital Records Section Burial - Transit Per�nit
Name First Middle Last Sex
Robert Allen Addison Male
x Date of Death Age q� If Veteran of U.S. Armed Forces,
September 6, 2013 N War or Dates World War II
Place of Death Hospital, Institution or
12' City, Town or Village Street Address
CI Manner of Death MA
izi Natural Cause El Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
C1; James Yovanoff, M.D. Dr.
Address
375 Bay Road#103 Queensbury, NY 12804
Death Certificate Filed District Nuumb�r Register per
City, Town or Village $ (J i
0 Burial Date Cemetery or Crematory
September 9, 2013 Pine View Crematorium
❑Entombment Address
. ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
0, and/or Address
p Hold
— Date Point of
Transportation Shipment
— by Common Destination
0 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
.` Address
t7C'
III
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9/f/c)p/,., Registrar of Vital Statistics 1/00 -.2- LA" " '
// (signature)
District Number 9/ Place 6/e,s ,/ 7ls; /IA/ /02-kr
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 111(413 Place of Disposition .,„Oi,w Cwwc'tr:6--,
2 (address)
11.1
ir, (section) A,. _
lot number) (grave number)
0 Name of Sexton or P rson in Cha a of Premises /^riN'
t3
(plea a print)
W Signature Title CT ""`*."I
(over)
DOH-1555 (02/2004)