Burrows, Robert Charles (2) mizzarzarnaratormaimeneasszaitiasiaanalriworaintsviallimmainallimmlomilm
Oct, 7. 2021;, 2:47PMFuneral Svc. 5086720647 -;.. -- page No, 9775 P. 1/1
'391
l�0 I s4,o
r Office of the State Medical Examiniers
y Certificate for Cremation
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aedorr removing a body to a Crematory,tho Funeral Director MUST obtain a completed Certificate for
Cremation from the Office of the State Medical Examiners. -7
Case Number. �1- l `T 3t,
1. Name of decedent Robert Burrows 1, 2, pate of death • Oct 5,2021
3a. Place of death�� — I
3b. City awn 1 4, Age
Rhode Island Hospital Providence 87
_5 Cause of Death ,.___._ —.———
Ruptured Abdominal Aneurysm, Hypertension
6. Autopsy(Yes or No) 7. Physician
No Kathleen Miller,MD
B. Funeral horns
South Coast Funeral Home
1555 Pleasant St. Fall River, MA 02723
I hereby certify that I have made Inquiry info the cause and manner of death,After such inquiry, It is my
opinion that no further examination or judicial inquiry concerning this death is necessary. PPennissbn is
herewith given to cremate the body or parts of the body of the decadent named above.
9a. Sig Meal' I 91).Date signed
•
Rhode I= _ . Department aal h,Office of Ine State Medical Examiner
48 Orms Street, Providence,RI 0291)4
a
To be Completed by Crematory
10a. Nype�crematory 10b.Date cremated
• I - 13 -zv74
lOc,c mown lad.State
ma y__
The Crematory shall send the original completed to R/DOH's Center for Vital Records
(3 Capitol Hill, Room WI, Providence, RI 02908) and shall retain a copy of this completed
form for its records.
AJo (aAL ade----
VS-37(Revised August 2018
BURIAL—TRANSIT' \410'11E ISLAND DEPARTMENT OF HEALTH
---.. --.a Permit number
DECEASED—FIRST NAME N.MIDDLE ,y, LAST SEX DATE OF DEATH..(Month,day,year)
Robert Charles. BURROWS Ap77 ( Male I D 105 1 'a ux‘
�, ^ PERMIT MUST RAGE,_ite Ae 7 PLgOro\AEff Cityeor,towp„state a Island
Accompany WIl Z3 YY CC tt((CCII
Remains to BURIAL,CREMATION,DONATION,OTHER(Specify) PLACE OF DISPOSITION(Name of cemetery,crematory or other place) CITY OR TOWN STATE
DESTINATION Cremation Pine-View Crematory Queensbury, New York
SEXTON must FUNERAL HOME—LICENSES FUNERAL HOME—Name and Address(Number,Street name,City or Town,State,and Zip Code)
, return permit to /) South Coast Funeral Home
CityorTown Signature 1555 Pleasant Street Fall River, MA 02723
w.
{‘<'Clerk at Place of
`, Disposal on Fifth CERTIFICATION:I certi at death occurred from natural causes,that(see Reverse Side)referral to the Medical Examiner is NOT required,and that permission is hereby granted to
of Next Month dispose of this body. M'• {'Cam/� - 1 O 2 0 Signature of '1
Physician Degree or title Date signed
Authorized/ disposition as stateabove occurred on(Date) Tomb Lot Signature f xton or Person in Charge of Place of Disposition
'/3 `
THIS PERMIT VALID ONLY IF SIGNED BOTH BY THE PHYSICIAN AND BY FUNERAL HOME LI SEE OTHER SIDE