Robinson, Harold F •
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Harold F Robinson Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/06/2021 82 Years War or Dates Unknown
H Place of Death Hospital,Institution or
Z City,Town or Village Amsterdam Town Street Address Capstone Center For Rehabilitation And Nursing
ILJ
p Manner of Death XI NaturalCause 0 Accident 0 Homicide ❑Suicide El Undetermined El Pending
W Circumstances Investigation
ILI M Certifier Name Title
Eyad Aldaas MD
Address
302 Swart Hill Rd,Amsterdam,New York 12010
Death Certificate Filed District Number Register Number
City,Town or Village Amsterdam 2850 89
ElBurial Date Cemetery,Crematory or Facility Name
08/09/2021 Pineview Crematory
0 Entombment Address
]Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
Cl) ❑Transportation
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
ElReinterment 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
F— Remains are Shipped,If Other than Above
2 Address
2
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2021 Registrar of Vital Statistics Linda Bartone-Hughes(Electronically Signed)
(signature)
District Number 2850 Place Amsterdam, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition g l IO N Place of Disposition ' 'n,c V L 4a.,
ILI
2 (address)
W
N
CC (section) / (lot number) (grave number)
O ti1rtipL 440
13 Name of Sexton or Person in Charge of I
Z (p ase print)
W ufrig
Signature Title � �
DOH-1555(07/18)p 1 of 2
ci I ,150.20
Public Health Law Sec. 4145(2b)
Receipt
Human remains of f delivered on , 20
e.
Pine View Cemetery Representing the funeral home named n burial permit
Official Funeral Directors Reg.or License#