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Robillard, Adam P 411 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Adam P. Robillard Male Date of Death Age If Veteran of U.S.Armed Forces, 01/26/2022 44 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Lake Luzerne Town Street Address 11 Gage Hill Road, Lake Luzerne Town, New York 12846 p Manner of Death Natural Cause 0 Accident EI Homicide ID Suicide El Undetermined ©Pending W U Circumstances Investigation 0 Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Lake Luzerne 5656 3 0 Burial Date Cemetery,Crematory or Facility Name 01/31/2022 Pine View Crematory Entombment Address lCremation Queensbury Town,New York ❑Donation ZRemoval Date Place Removed and/or and/or Held F— Hold Address N 0 d Date Point of Cl) LI Transportation p by Common Shipment Carrier Destination Date Cemetery Address El Disinterment 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 1— Remains are Shipped,If Other than Above N Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/31/2022 Registrar of Vital Statistics Cynthia Sherwood(Electronically Signed) (signature) District Number 5656 Place Lake Luzerne, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: // WDate of Disposition I/31 1 Z Z Place of Disposition I "'- .VV.— l✓�d r0�2 (address) LU Cl) (section) AI (lot number) _ t (grave number) 0 Name of Sexton or Person in Charge of Premises2 U �r+ � ��^�1 1 z /p! se print/ / W Signature Title (run+ �o DOH-1555(o7/18)p 1 of 2 01 5 594 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#