Robbins, Hal NEW YORK STATE DEPARTMENT OF HEALTH it 520
Vital Records Section i( 1 Burial - Transit Permit
Name First Middle Last Sex
Hal Gibson Robbins Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 29, 2012 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hartford Street Address 119 Gilchrist Hill Road
Manner of DeathEl Natural Cause El Accident El Homicide ❑ Suicide ❑Circumstances Investigation
Undetermined El Pending
`
i�i Medical Certifier Name Title
Edward S. Parsons, III
Address
17 Prospect Street Granville, NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village Hartford
0 Burial Date Cemetery or Crematory
October 1, 2012 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
°, ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
f by Common Destination
Ct Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remai desaibed e i dicat d.(Lim(
Date Issued l 0 Z. Registrar of Vital Statistics U
q R
kit'A ) (signature)
District Number 51 \ Place O.A-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/01/2012 Place of Disposition Quaker Road Queens bury,NY 12804
(address)
(section) ,j (lot number) (grave number)
Name of Sexton or Pers. in Charge of remises ittill t- ft"*
+ ;. (please print)
Signature /�► Title Cfhr MR
-0-- ;
(over)
DOH-1555 (02/2004)