Gardner, Robert I
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section Last Sex
Middle MALE
Name First L, . GARDNER
ROB If Veteran of U.S. Armed Forces,
Age
Date of Death 78 War or Dates tiJ`1 2
Dec, 27 , 1999 Hospital, Institution or
Place of Death KeenU Street Address Pending
City, Town or Village Undetermined g
Manner of Death❑Natural Cause Accident Homicide Suicide
Circumstances Investigation
Title
Medical Certifier Name
�T o
hn M. E 1 , MD
AddressNY
Adr k Medical Center, Saranac Dstrict'Number Register Number
Death Certificate Filed 1555
City, Town or Village Keene Cemetery or Crematory
Date pine View Cremator
❑Burial DEC, 28 , 1099
Address
QCremation Glens Fall , NY
Place Removed
Date and/or Held
g Removal
❑and/or Address
Hold
Date Point of
Q Shipment
❑Transportation
0 by Common Destination
Carrier Cemetery Address
_
Disinterment Da.te
— I Date Cemetery Adress
d
Reinterment Registration Number
Permit Issued to 01231
`< Name of Funeral Home`'I• :3• Clark, Inc'
Address 12946
27 Saranac Ave. , Lake placid, N. Y.
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[above�as indicated.
Date Issued 12/2 8/9 9 Registrar of Vital Statistics
(signature)
`s District Numbers Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition i2--2 Place of Disposition.
(address)
(section) (lot nu ber) (grave number)
O Name of Sexton or Person in Charge of Premises 9 A 1Z.1.a &Q.
n (please print)
W. Signature
Title 0' 12
DOH-1555 (10/89) P. 1 of 2 VS-61