Putnam, Robert NEW YORK STATE DEPARTMENT OF HEALTH 1 13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert C. Putnam Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 27,2012 82 War or Dates World War II
ilPlace of Death Hospital, Institution or
; City, Town or Village Gansevoort Street Address 190 Palmer Ridge Rd.
tl f, Manner of Death in Natural Cause pi Accident I I Homicide X Suicide 'Undetermined 'Pending
Circumstances Investigation
Medical Certifier Name Title
, Michael Sikirica,MD
Address
50 Broad Street,Waterford NY 12188
Death Certificate Filed District Number Register umber
City, Town or Village Wilton/ �/`
❑Burial Date Cemetery or Crematory" "
❑Entombment October 1, 2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ I (Removal and/or Held
5 2and/or Address
H Hold
N
0 Date Point of
yI I Transportation Shipment
p by Common Destination
Carrier
I !Disinterment Date Cemetery Address
1-7 Reinterment Date Cemetery Address
▪ Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
▪ Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
I4, Remains are Shipped, If Other than Above
S Address
us
Ai
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /0//_,2 Registrar of Vital Statistics #141 ,L �� �s' i na ure
( 9 )
District Number Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LUDate of Disposition so f zf it Place of Disposition -g,eRct„) C r w--
Z (address)
N
M
(section) / _ (lot number) (grave number)
Z Name of Sexton or Person in Charge o Premises Ant „,, --
J' (please print)
W Signature Title C4 o, .
(over)
DOH-1555(02/2004)