Robinson, Daivd NEW YORK STATE DEPARTMENT OF HEALTH • i ' c c
Vital Records Section Burial - Transit vermit
' Name First Middle Last Sex
David Robinson Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 15, 2012 65 War or Dates
' Place of Death Hospital, Institution or
`Z City, Town or Village Lake George Street Address 32 Bloody Pond Rd.
US
121. Manner of Death I)(I Natural Cause Accident ❑Homicide Suicide Undetermined Pending
All Circumstances Investigation
Ks Medical Certifier Name Title
elP Darci Gaiotti-Grubbs,MD
Address
:i 102 Park Street,Glens Falls,NY 12845
Death Certificate Filed District Number Register Number
City, Town or Village Lake George 5 LO 1 (4¶O
❑Burial Date Cemetery or Crematory
October 17, 2012 Pine View Crematorium
❑Entombment Address
Ex Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
' ; Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
air Name of Funeral Firm Making Disposition or to Whom
I► Remains are Shipped, If Other than Above
g Address
Its
us,
._: Permission is hereby granted to dispose of the huma • described above as indicated.
Date Issued /v -/ 7- l Registrar of Vital Statis ' j\ Qi
< (signature)
/
District Number Place Lake George
▪ I certify that the remains o the decedent identified above were disposed of in accordance with this permit on:
Z Place of Disposition gra,tht,"") (,rG-litz—
W Date of Disposition I�'22�(Z, P
W (address)
CO
re
(section) _viof numb4. (grave number)
pName of Sexton or Person in Charge of P emises //i� t
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Signature . .. Title " ki 2
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DOH-1555(02/2004)