Robinson Jr., George Thomas ttikk
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
George Thomas Robinson Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/26/2021 93 Years War or Dates 1946-1948
Place of Death Hospital,Institution or
WCity,Town or Village Lake Luzeme Town Street Address 5 Fenway Drive,Lake Luzerne Town, New York 12846
p Manner of Death Natural Cause El Accident Homicide El Suicide ❑Undetermined ❑Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
CI Bryan Smead MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Lake Luzerne 5656 12
❑Burial Date Cemetery,Crematory or Facility Name
07/30/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
v Hold Address
0
CL Date Point of
U) ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
g Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/30/2021 Registrar of Vital Statistics Cynthia OerwoodlElectrnnicalySignea9
(signature)
District Number 5656 Place Lake Luzerne, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H -���
WDate of Disposition 73) 0AI Place of Disposition - e V e Croy. M1ti
2 (address)
W
N CC (section) (lot number) (grave number)
1
ycJ0 Name of Sexton or Person in Charge of Pr is s 1� A y►�d C k/
Z � (please print)
W Signature °.4/✓1/ Title pefu
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 014 9'3 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#