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Miksch, Robert Henry If 17 g NEW YORKSTATE DEPAAT:MENTOF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Henry Miksch Male Date of Death Age If Veteran of U.S.Armed Forces, 02/14/2021 91 Years War or Dates 1948-52 F Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital "p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined El Pending t? Circumstances Investigation LIJ Medical Certifier Name Title 0 Gamal Khalifa MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 100 Burial Date Cemetery,Crematory or Facility Name 02/17/2021 Pine View Crematory E Entombment Address L^__I Cremation Queensbury Town,New York Donation Z Date Place Removed Q El Removal and/or Held P- and/or N Hold Address 0 0. 1-1 Li Transportation Date Point of by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address E Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom j Remains are Shipped,If Other than Above • Address C w a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/16/2021 Registrar of Vital Statistics R 6ertAndrew Curtis(E(ectronicaffy Signer (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z U.1 Date of Disposition 2)i1 i II Place of Disposition _ L, 2 (address) Ili Cr N (section) (lot nu ber) (grave number) O Name of Sexton or Person in Charge of Premises (/i p.�hro�. h,A 411 Z (please print)i W Signature :�2Title lc4mq12 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) . 14 5 4 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funerallrome named on burial permit Official Funeral Directors Reg.or License#