Barrett Sr., Robert Edward 1 tO
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Edward Barrett Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/12/2021 72 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Argyle Town Street Address 273 County Route 45,Argyle Town,New York 12809
`p Manner of Death Natural Cause ElAccident ❑Homicide ElSuicide ❑Undetermined ❑Pending
U Circumstances Investigation
ILI Medical Certifier Name Title
Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 76
❑Burial Date Cemetery,Crematory or Facility Name
12/17/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
Hold Address
N
0
EL 1-1 U) ❑Transportation
Date Point of
by Common Shipment
Carrier Destination
Date Cemetery Address
El Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
F-. Remains are Shipped,If Other than Above
2 Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/16/2021 Registrar of Vital Statistics Shelley 9i1ckgrnon(ECectronicalrySigned)
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II— Q
W Date of Disposition /2-f U-Z.02r Place of Disposition !t.)e lJ e)
2 (address)
W
CC CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge o remises 'RA 1 `77!?.� 1.-000\
Z (please print)
W Signature i<> ��� Title 0te)-7-_
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
� 154 51.
Receipt
Human remains of delivered on , 20
• Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#