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Gundel, Robert G.
1 Z25 • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert G.Gundel Male Date of Death Age If Veteran of U.S.Armed Forces, 11/14/2020 89 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Indian Lake Town Street Address 1128 Big Brook Road, Indian Lake Town, New York 12842 LLI p Manner of Death ©Natural Cause ❑Accident El Homicide ❑Suicide Undetermined 0 Pending W Circumstances Investigation W Medical Certifier Name Title CI Melanie Duerr NP Address 47 Tom Phelps Lane,Mineville Hamlet,New York 12996 Death Certificate Filed District Number Register Number City,Town or Village Indian Lake 2053 14 ElBurial Date Cemetery,Crematory or Facility Name 11/21/2020 Pine View Crematory 0 Entombment Address Cremation Queensbury Town,New York El Donation ElDate Place Removed Removal and/or Held H and/or Hold Address 00.. Date Point of co 11 Transportation Shipment p by Common Carrier Destination 0 Disinterment Date Cemetery Address Date Cemetery Address 0 Reinterment Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address W • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/16/2020 Registrar of Vital Statistics Julie A Clawson(Electronically Signed) (signature) District Number 2053 Place Indian Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 1— Z Date of Disposition /1"Z3-Zo Z.() Place of Disposition 7)71 e-117-C,3 (-T€* I - 1 tU (addZc) W CC (section) k (lot number) (grave number) 0 Name of Sexton or Pe n in arge of Premises f" `�i4 4'1`� Q (please print) W Signature v Title G/eyyt44/y d//�2�a./�/ DOH-1555(07/18)p of 2 Public Health Law Sec. 4145(2b)- 1421. Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# -1