Simmons, Robert K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
>' Robert Kendrick Simmons male
Date of:. :::::.:..::.............................................. .......
Death Age If Veteran of U.S.Armed Forces,
2/11/1990 65 War or Dates World War II
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Place of Death Hospital, Institution or
City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
f� Cause of Death P:..::::..:.::::..:.........:.....
- ' multiple ::ulmonar embolii due t_ cancer of the lun
.P . . pulmonary::.Y.. .............:::.:::::............P. :.:.:...:::..... 9.....
Medical Certifier Name Title............
C William Tedesco MD
..............................:::..::AddreSs'::,..............................................................................................................................
...........................
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17 Pine Street, Glens Falls, New York 12801
.:.
;::..Death Certificate:.:.: ....
Filed District Number ` Register Number
::::::..........
City,Town or Village City of Glens Falls
Date Cemetery or Crematory '
❑Burial
:....:::..:........:.........:....:.:::::::::. .. .......:......::::..::.:::::..:....:...:..:.::::.Pin�.::11.�e w.::��:e m a�.Q.�.y..........::.:.:::::....:........
..........
(Cremation .
Address .:..........:::::::::::........::::
Town of Queensbury, New York
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Z Date Place Removed
O! ❑ Removal and/or Held
r and/or Hold ...:...:...:....... .......................:::.::::::.........:........................:....:. ....
Address
G Date Point of
❑Transportation by: Shipment
Common Carrier ..............................
Destination
. .......................................:..:.....................:. ... ..........
❑ Disinterment Date Cemetery Address
..
❑ Remterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm R an and _ _ . ervice, Inc. 01634 Denny Funeral
..Address
26 Quaker Road.,....Queensbur ..,....New...York.............12804...........................................................................................
..............................._......:......w..................::::..:::::::::.,......... .
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
..
Permission is herb :ranted to dispose of the hums ains described bove a :Indicated.
Date Issued Registrar of Vital Statistics
/ (s ature)
District Number 4Place l
I certify that the remains of the decedent i ntified above were disposed of in accordance with this permit on:
Z< Date of Disposition '-1 Q Place of Disposition ,f I/I y�jl z;,6 7®�/ W
(address)
w
(section) (lot number) (grave number)
o� g � r9�t'h r� 7'/����
p' Name of Sexton r Person i Char a of Premises
Z �y `�
W Signature 1�iL�fGG �. (Please print)Title /}lC1 Rl' .�s/�
DOH-1555(9/86)p 1 of 2(formerly VS-61)