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Fuller, Robert Leonard . $ 16-) NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Leonard Fuller Male Date of Death Age If Veteran of U.S.Armed Forces, "` 02/17/2022 76 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Fort Ann Town Street Address 51 Crawford Lane,Fort Ann Town,New York 12839 Manner of Death ©Natural Cause Accident El Homicide El Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title David Foote MD Address 340A Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed District Number Register Number City,Town or Village Fort Ann 5754 7 ❑Burial Date Cemetery,Crematory or Facility Name 02/22/2022 Pine View Crematory ❑Entombment Address i 0 Cremation Queensbury,New York 'ii Donation goRemoval Date Place Removed and/or and/or Held pto Hold Address C A. Date Point of e❑Transportation Shipment by Common Carrier Destination A 4, Disinterment Date Cemetery Address .d ❑Reinterment Date Cemetery Address ,1, 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 Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/22/2022 Registrar of Vital Statistics Barbara Y Winched(ECectronicaCCySigned) (signature) mow, District Number 5754 Place Fort Ann, New York a ) - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition Zj Zy I ZZ. Place of Disposition IL / 4-pf w✓--, (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of mises /� � "��i 2 (plead print) f. 1111 si Signature Title `Pf- ti 7Ve DOH-1555(07/18)p 1 of 2 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#