Mattison, Jr. Robert NEW YORK STATE DEPARTMENT OF HEALTH 4 I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Walter Mattison Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 5, 2012 53 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ct Manner of Death fl
u Natural Cause 0 Accident Homicide El Suicide 0 Undetermined IT Pending
LU
Circumstances Investigation
WCU Medical Certifier Name Title
Frances Bollinger MD,
Address
161 Carey Rd Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 5601 -5 7
`, ,Burial Date - Cemetery or Cramatnn,
April 2, 2012 pine View Crematorium
❑Entombment AririrPas
54Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
z ri Removal and/or Held
a and/or Address
Hold Union Ce• :tery
CA Date Point of
Transportation Shipment
(I) by Common Destination
1- Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
x Name of Funeral Home Carleton Funeral Home, Inc. 00281
x 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
2 Address
W..
'"= Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Lgb 6/� Registrar of Vital Statistics ,, 0_,j. 'j .
(signature)
District Number f'jl, Place b rxj `
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w1-` I� � J�
Date of Disposition til 3l totz Place of Disposition ,�V Civ +Yl�,�,
1 (address)
UI
r (section) (lot number) (grave number)
` 3Y Name of Sexton or Per on in Charge of Premises �r�Jt � c
Z (please print)
Signatures -T— Title C2EMA-lOIL ll
1�
(over)
DOH-1555 (02/2004)