Loading...
Carlsen, Robert NEW YORK STATE DEPARTMENT OF HEALTH `'y Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Carlsen Male Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2022 89 Years War or Dates Army Place of Death Hospital,Institution or Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing UJ p Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title G Joshua Starteri NP Address 10421 State Route 40,Granville Town,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 5756 3 ❑Burial Date Cemetery,Crematory or Facility Name 01/21/2022 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury,New York ❑Donation g ❑Removal Date Place Removed and/or and/or Held H Hold Address (!1 ❑Transportation Date Point of by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom — Remains are Shipped,If Other than Above ,'.2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2022 Registrar of Vital Statistics Jenny Lineal,'Wartellee(ECectronicallySigned) (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Zl t 27_ Place of Disposition En(IL- 2 (address) W (I) (section) , (lot number) (grave number) gName of Sexton or Person in Charge of Premises A Z tease print) W Signature Title (00191-012 DOH-1555(07/18)p 1 of 2 5 5 ., Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20,. Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#