Matraw Jr, Robert G. 2c
NEW YORKSTATE DEPARTMENT OF HEALTH Burial -Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert G Matraw Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/09/2021 78 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death Natural Cause 0 Accident 0 Homicide El Suicide El Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
C3 Yoram Amsalem MD
Address
` 211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 194
❑Burial Date Cemetery,Crematory or Facility Name
03/11/2021 Pineview Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or Held
Hold Address
0
0. Date Point of
N Q Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
cr
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
22 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W )
I'
Date of Disposition 31 i11 Z,1 Place of Disposition
(a d ss)
W
ce (section) `�potnumber) (grave number)
8 Name of Sexton or Person in Charge of Premises E n `"' `...3 "41T
(pleas print)
W Signature Title ` � �—
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 1 4 630
Receipt
Human remains of delivered on , 20
•
Pine View Cemetery Representing the funeral home named on burial Kermit
Official Funeral Directors Reg.or License#