Jones, II. Robert 0
I NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Lewis Jones II Male
Date of Death Age If Veteran of U.S. Armed Forces,
470 02/15/2018 62 Years War or Dates
Place of Death Hospital, Institution or
14 City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death a Natural Cause Accident 0 Homicide Suicide Undetermined �Pending
Circumstances Investigation
w Medical Certifier Name Title
CI Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
n City, Town or Village Glens Falls 5601 92
a[]Burial Date Cemetery or Crematory
02/20/2018 Pine View Crematorium
Li Entombment Address
®Cremation Queensbury Town, New York
1 Date Place Removed
0❑Removal and/or Held
!+= and/or Address
Hold
Q, Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment
Date Cemetery Address
q ri
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/20/2018 Registrar of Vital Statistics RpbertA Curtis(ElectronicaffySigned)
#«; (signature)
District Number 5601 Place Glens Falls, New York
E I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
LU Date of Disposition Z/ZI (t3 Place of Disposition �,u Vw .. ._
r` (address)
W'
(section) ,4 (lot numbe (grave number)
O Name of Sexton or Person in Charge of, remises j 1(4 '-
Z (p ase print)
tt Signature /r'/ Title fa ry.4-
(over)
DOH-1555 (02/2004)