Lemery, Robert 't/ t
NEW YORK STATE DEPARTMENT OF HEALTH - I Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ROBERT MICHAEL LEMERY MALE
, Date of Death Age If Veteran of U.S.Armed Forces,
a 1/23/2018 57 War or Dates 1978-1979
-5 Place of Death Hospital, Institution
Z' Ci• ty ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
a Manner of Death Natural Undetermined Pending
® El Accident El Homicide ❑ Suicide El ❑
'° Cause Circumstances Investigation
uji M• edical Certifier Name Tit►e
CI KRAIG WASIK MD
1 Address
AMC 43 NEW SCOTLAND AVE., ALBANY, NY 12208
Death Certificate Filed District Number Register Number
C• ity,Town or Village City of Albany 101 0196
Date Cemetery or Crematory
❑ Burial 01/29/2018 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
I-- Hold
in
0 Date Point of
a. Transportation Shipment
❑ By Common
a Carrier Destination
❑ Disinterment Date Cemetery Address
I] Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. KILMER FUNERAL HOME 01079
Address
182 BROADWAY FORT EDWARDS, NY 12828
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
2_ Address
L
a` Permission is hereby granted to dispose of the human remains described above as indicated.
1/26/2018
Date Registrar of Vital Statistics
..........
Issued
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this/permit on:
Z Date of Disposition l/30 laS Place of Disposition &V-1 j&.cl.�..
W (address)
2
w
co
ct (section) (lot number) c (grave number)
0
t3
WName of Sexton or Person in Charge of Premises f,-hpr< ,� it....lit
(please print)
Signature 4 A TitleL
(over)
DOH-1555 (02/2004)