Kemmer Jr., Robert R t t 2?
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert R Kemmer Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/03/2022 62 Years War or Dates
ZPlace of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
QManner of Death II Natural Cause Accident 0 Homicide 0Suicide Undetermined Pending
0 Circumstances Investigation
0 Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 147
Burial Date Cemetery,Crematory or Facility Name
03/08/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d 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 Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i-. 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 03/08/2022 Registrar of Vital Statistics £Megan Noun(E(ectronica((ySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3-12_20,42 Place of Disposition ,✓e (J,`e,,J ` p'it , q-fo A`c(
(address)
W
Q (section) (lot number)
(grave number)
GName of Sexton or Person in Charge of remises 1�AY/7ll�n//� jwoc✓
Z (please print)
IL Signature ijj/ Title
DOH-1555(07/18)p t of 2
iv-".
) 1 F:P7r,
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#