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Pickett, Robert NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Robert Floyd Pickett Male Date of Death Age If Veteran of U.S. Armed Forces, War or Dates :.:.:.:.:.Place of Death Hospital, Institution or City, T Street Address Manner of Death Undetermined Pending FC]Natural Causes Accident Homicide Suicide Circumstances Investigation Medical Certifier Name Title Mi chael Adam., MD Address Moreau Family Heal t Death Certificate Filed District Number Register Number City, T06ft0a Glens Falls 5601 j Z Q ❑ Burial Date Cemetery or Crematory October 1999 Pine View Crematorium © Cremation Address Tn of Queensbtuy, NY 12804 Date Place Removed ❑ Removal and/or held and/or hold Address Date Point of ❑ Transportation by Shipment Common Carrier Destination Date Cemetery Address ElDisinterment Date Cemetery Address ❑ Reinterment ::::::>:Permit issue to Registration Number Name of Funeral Firm Carleton Funeral Herne InC. 00297 Address P.O. Box 67, 68 Main St. , Hudson Falls, N.Y. 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described ab a as ind' at Date Issued Registrar of Vital Statistics (Signature) District Number 5601 Place Glens Falls, NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition Place of Disposition Pjdti ,1 ` cr e m a T0-y (address)- (Section) (Lot Number) (Grave Number) Name of Sexton or Person in Charge of Premises (Please Print) Signature$ �V- Title C a,- y DOH-1555 (10/89) p. 1 of 2 VS-61