Ireton, Robert NEW YORK STATE DEPARTMENT OF HEALTH `: R ' 4 736
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert E. Ireton Male
iiiip Date of Death Age If Veteran of U.S. Armed Forces,
ig 09/27/2018 78 years War or Dates No
j Place of Death Hospital, Institution or
XXXACTown orXRDWA Glenvillela Street Address 72 Fredericks Road
Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined ❑Pending
I0 Circumstances Investigation
la Medical Certifier Name Title
14 Mina Sun M. D.
Address
463 Saratoga Road, Glenville, N Y 12302
Zliii Death Certificate Filed District Number Register Number
iM Y419,(Town orXXIMA Glenville 4651 131
iiM❑Burial Date Cemetery or Crematory
10/02/2018 Pine View Crematorium
❑Entombment Address
Cremation Queensbury, N Y
Date Place Removed
❑Removal and/or Held
and/or
Et: Hold F
Hold
41)
0 Date Point of
El Transportation Shipment
0 by Common Destination
Si Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration1 Number
Name of Funeral Home Regan Denny Stafford Funeral Home
>< Address
53 Quaker Road, Queensbury, Ny 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
l
Permission is hereby granted to dispose of the human remai = de-cribed above a indicated.
Date Issued 09/28/2018 Registrar of Vital Statistics -Ali ,y fds (1.
ign ure)
iiii District Number 4651 Place Glenville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k A
la Date of Disposition /6 f z( Place of Disposition full, 4.,,,i er... .,
i ► (address)
w
40
ix (section) A(Iot
number) c (grave number)
ci f
Name of Sexton or Person in Charge of Premises ,1 t QnAgit
2 (pleOse print)
Signature t'- Title
(over)
DOH-1555 (02/2004)