Livingston Jr., Robert L # 33
NEWYORKSTATEDEPARTMENTOFHEALTH _
Bureau of Vital Records B(COFurial Transit Permit
Name First Middle Last Sex
Robert L.Livingston Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/11/2022 71 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
111
1pManner of Death LE NaturalCause El Accident ❑Homicide ID SuicideEl Undetermined ❑Pending
U Circumstances Investigation
W Medical Certifier Name Title
0 Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 8
❑Burial Date Cemetery,Crematory or Facility Name
01/11/2022 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town, New York
ElDonation
g Removal Date Place Removed
and/or and/or Held
Hold Address
0
O. Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/11/2022 Registraro#'Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ( f IL I ZZ Place of Disposition
W
2 (address)
W
CC CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises a,s Stin.itt
Z (p se print)W Signature Title ree441Pt
DOH-1555(07/18)p t of 2
.s ...
Public Health Law Sec. 4145(2b)
Receipt
Human remains of r delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#