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Mackey, Robert it I YORK STATE DEPARTMENT OF HEALTHillRecords Section 0 Burial - Transit Permit 141 ,i Name First Middle Last Sex MaleRobert L. Mackey Date of Death Age ; If Veteran of U.S. Armed Forces, 3/12/2012 58 i War or Dates No Place of Death I Hospital, Institution or City. ii�l Glens Falls _ Street Address 40 Cunningham Ave. Manner of Death Natural Cause ©Accident ❑Homicide 0 Suicide Undetermined Pending Circumstances Investigation ��Medical Certifier Name ,Titi ciel_ e ddressQ -it Death Certificate Filed 7 District Number I 3 Regis er Number <, City• Glens Falls 5601 i as Date Cemetery or Crematory ❑Burial z 3/16/2012 Pine View Crematory Address Li Cremation Queensbury,NY Date Place Removed ❑Removal _ and/or Held and/or Address — Hold Q Date ' Point of - NQ Transportation Shipment Ei by Common Destination Carrier t _ _ El Disinterment I Date Cemetery Address Reinterment Date Cemetery Address ,' Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home, Inc. 00211 Address 24 Church St., Lake Luzerne,NY 12846 a 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 remains d crib d ov ndicated. Date Issued 0 3 Pe ao/� Registrar of Vital Statistics �� (signature) //� District Number C 0/ Place �� � ` `/ /vy • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I.- WDate of Disposition 3-it,-.7a i 7 Place of Disposition P.ne a t'e C le w c..to n ,.,., vr 2 (address) W (I) LC (sin) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises t ,',v„oAki ; rcmc(le W .___� (please print)r / Signature , et Title Ct a wtc, ry �S5 DOH-1555 (10/89) p. 1 of 2 VS-61