McSweeney, Robert NEW YORK STATE DEPARTMENT OF HEALTH IiiI
Vital Records Section 1 Burial - Transit Permit
` Name First Middle Last Sex
Robert Clarence McSweeney Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 3, 2012 85 War or Dates World War II
_t Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death X❑ Natural Cause 0 Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
ILIu.
Circumstances Investigation
Medical Certifier Name Title
' ` David Foote Md,
Address
Rt 4 Hudson Falls, NY 12839
Death Certificate Filed District Number RegisterJ,Vuber
City, Town or Village 5601
;. ❑Burial Date Cemetery or Crematory
Pine View Crematorium
El Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
z and/or Address
Hold
f Date Point of
lle:'E Transportation Shipment
_0 by Common Destination
O Carrier
Disinterment Date I Cemetery Address
❑
Date Cemetery Address
III Reinterment
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
H Remains are Shipped, If Other than Above
2 Address
W`
0.. Permission is hereby ranted to dispose of the human mains cribed ab ye as indi ated.
Date Issued O5 Registrar of Vital Statistics
� ��
ignature)
District Number 5601 Place A �� /' �4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
W. Date of Disposition 5/1I(Z Place of Disposition RiP C 6rn,
(address)
W.
(section) (lot number) c'14
(grave number)
O Name of Sexton or Per n in Charge .� Premises Y•-' '
(pl ase print)
W'' Signature /u �� Title
(over)
DOH-1555 (02/2004)