Robbins, John Erwin (!) 4 3 z-)
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Erwin Robbins Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/12/2022 81 Years War or Dates 1961-1965
H Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
a Manner of Death ID Natural Cause Accident Homicide ❑Suicide Undetermined ❑Pending
W
V Circumstances Investigation
CMedical Certifier Name Title
Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town of Fat Edward District Number Register Number
0,Town or 5755 37
Burial Date Cemetery,Crematory or Facility Name
04/18/2022 Pine View Crematory
Entombment
Address
Cremation Oueensbury Town,New York
Donation
,Z Date Place Removed
0 Removal and/or Held
p and/or
a Hold Address
0
O. Date Point of
CO❑Transportation
ES by Common Shipment
Carrier Destination
Date Cemetery Address
❑DisintermentEl
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped,If Other than Above
`N• Address
IS
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2022 Registrar of Vital Statistics Aimee Lgtalwncy(EYictro Si nea)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
Z Date of Disposition gUWIZZ CAA--
Place of Disposition -�+�tu�_ �JRj--
IW
a (address)
W
CC (section) 4 i (lot numbe (grave number)
gName of Sexton or Person in Charge of P Rises i ni i... rit4ltt
Z lease prnt
W C �-P Signature Title 'L
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#