Jenkins, Robert NEW YORK STATE DEPARTMENT OF HEALTH '''wf " 111 # S 73
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Edward Jenkins Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 10, 2018 81 War or Dates
Place of Death Hospital, Institution or
ill City, Town or Village South Glens Falls Street Address 4 New Street
Manner of Death❑Natural Cause 0 Accident Ej Homicide 0 Suicide riUndetermined riPending
Circumstances Investigation
Medical Certifier Name Title
Daniel J. Kuhn,
Address
40 McMaster Street Ballston Spa, NY 12020
Death Certificate Filed District Number Register Number
-: City, Town or Village South Glens Falls
❑Burial Date Cemetery or Crematory
July 16, 2018 Pine View Crematory
O Entombment Address
7 alCremation Quaker Road Queensbury,NY 12804
Date Place Removed
7�
Removal and/or Held and/or
Hold Address
Date Point of
IL ❑ ransp
T ortation Shipment
.
0 by Common Destination
Ci Carrier
rjDisinterment Date Cemetery Address
-;Ej Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
te
ILI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0 f-/; p/g Registrar of Vital Statistics (. ----'l
(signature)
District Number 4 6- 7 Place V ! l(CT 01 )0tL yZ (7 El t-G ��S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ww Date of Disposition 07/16/2018 Place of Disposition Quaker Road Queensbury,NY 12804
Z (address)
i
DIDI (section) /Al(lot number) (grave number)
( ^`�
Name of Sexton or Person in Charge of Premises 'r 3,"
(Obese print)
I Signature 4 / Title firtc*itlit
(over)
DOH-1555 (02/2004)