Conlin, William Robert ii sCz
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
William Robert Conlin Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/05/2021 85 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
ILI
p Manner of Death 0 Natural Cause El Accident El Homicide Suicide Undetermined 0 Pending
W Circumstances Investigation
U W Medical Certifier Name Title
O Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 139
❑Burial Date Cemetery,Crematory or Facility Name
07/07/2021 Pine View Crematory
,a Entombment Address
0 Cremation Queensbury,New York
Donation •
Date Place Removed
0 ❑Removal and/or Held
— and/or
N
Hold Address
0
Date Point of
f/) Li Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
v X'
. a Date Cemetery Address
ElReinterment;
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
E.. Remains are Shipped,If Other than Above
5 Address
IC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/07/2021 Registrar of Vital Statistics Carolnexk4ar&Bader(Electronicall:y Signet!)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~
W Date of Disposition ,11 (1,` Place of Disposition
u IL I'1I� c�
/a( dress)
W
N (section) /lat number)Jave number)
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0 _. ...___ ,"--- „fit
O Name of Sexton or Person in Charge of P emises /p elet as rintl
Z /
((*�M441 L
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) : 14 9
4'
Receipt
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Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#