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VanEtten, Robert L NEW YORK STATE DEPARTMENT OF HEALTH ; Burial - Transit Permit Bureau of Vital.Records Name First Middle Last Sex Robert L.VanEtten Male Date of Death Age If Veteran of U.S.Armed Forces, 08/23/2021 69 Years War or Dates Place of Death Hospital,Institution or III City,Town or Village Fort Ann Village Street Address 12 Catherine Street, Fort Ann Village, New York 12827 a Manner of Death ©Natural Cause Ll Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending 10 U' Circumstances Investigation QMedical Certifier Name Title John Quaresima MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann Village 5723 3 Burial Date Cemetery,Crematory or Facility Name Entombment 08/24/2021 Pineview Crematorium Address 0 Cremation Queensbury Town,New York ❑Donation 4 ❑Removal Date Place Removed -- tl� and/or and/or Held a Hold Address 1)�Transportation Date Point of Es by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom t... Remains are Shipped,If Other than Above ' Address CC CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/23/2021 Registrar of Vital Statistics Barbara J Winchell (Electronically Signed) (signature) District Number 5723 Place Fort Ann Village, New York 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ui Date of Disposition „,,y.',, Place of Disposition (address) Lt 0 (section) (lot number) (grave number) .§ Name of Sexton or Person in Charge of Premises ��(p+t,y' S`.V;rG� z (please print) SU Signature Title / li ei r,edk'i 1r DOH-1555(07/18)p 1 of 2 i Public Health Law Sec. 4145(2b) Receipt . . 3 1 5 06 7 1 i..: ,..., i Human remains of - ,:-/-. I ' -.. ,.. ./e. .e://`7 ' ,,A delivered on . / . - ,'/ , 20 "----f k°_ -,,',/,',.- .,/\ --- -- -Pine View Cemetery Representing the funeral home named 90,4urial/pe7nit Official Funeral Directors Reg.or License# /