Krug, Robert 1 iJ
NEW YORK STATE DEPARTMENT OF HEALTI4_
Vital Records Section Burial - Transit Permit
Name First •le Last Sex
Robert Krug Male
Date of Death Age -ran of U.S. Armed Forces,
12/5/2018 95 War or Dates Army
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 105 Coolidge Ave
au
p Manner of Death F Natural Cause n Accident ❑Homicide n Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ut Medical Certifier Name Title
0 Christopher Hoy,MD
Address
Queensbury,NY
Death Certificate Filed Dist t Number Register Number
City, Town or Village Queensbury,NY 5657 CC2 ')
❑Burial Date Cem tery or Crematory
❑ December 7,2018 Pine View Crematorium
Entombment
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z
n Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address
CC
Permission is hereby granted to dispose of the human re\\ins__ described ov as indicated.
Date Issued )0)-I"1 c�p 1 ( Registrar of Vital Statistics Y� `-sc'1.
(signature)
District Number g(c'-) Place ) � �') -( fie
I certify that the remains of the decedent identified above were disposed of in a cordance with this permit on:
ILJI Date of Disposition la-a--to-t Y Place of Disposition 11;1, , 1f eeiLJ cCc, ay
(address)
Cl)
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises JedfMLY Ste„CLS
(please print)
W Signature 4/ rw Title C-,ft►titct E or
(over)
DOH-1555(02/2004)