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Russell, Robert Paul I Lb NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Paul Russell Male Date of Death Age If Veteran of U.S.Armed Forces, 01/23/2021 43 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Bolton Town Street Address 15 Braley Lane,Bolton Town,New York 12814 WManner of Death ❑ Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ©Pending Circumstances Investigation 0 Medical Certifier Name Title 0 Lynn Keil PA Address 1340 State Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Bolton Landing 5650 1 ❑Burial Date Cemetery,Crematory or Facility Name 02/05/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation ElRemoval Date Place Removed and/or and/or Held F-N Hold Address 0 Q. 1-1 Date Point of t/) ❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above Address w CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/05/2021 Registrar of Vital Statistics Jodi L Connally(Electronically Signed) (signature) District Number 5650 Place Bolton Landing, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:1% Date of Disposition �-,a,p,Z,1 Place of Disposition (;); )e kh-e--QJ C fGjs1�-fps I 2 (address) w CO CC (section) '�I_ //otnum�be�r/ (grave number) SName of Sexton or Person in Charg f Premises , l dono� r' ux t 1 Z r � ` /(please print) W Signature J ,f yff ///////{ Title o `"��'�1 DOH-1555(o7f18)p 1 of 2 Public Health Law Sec. 4145(2b) 0 1 ti- 510 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#