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Sipowicz, Robert B Jr. NEW Y©RKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert B.Sipowicz Jr. Male Date of Death Age It Veteran of U.S.Armed Forces, 04/08/2022 65 Years War or Dates Place of Death Hospital,Institution or W City,(own or Village Glens Falls Street Address Glens Falls Hospital Martnervl Death I I Natural Cause Accident Hornicide []Suicide ❑Undetermined ❑Pending I I Circumstances Investigation CI Medical Certifier Name Title Marcille Labban 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 206 []Burial Date Cemetery,Crematory or Facility Name 04/11/2022 Pine View Crematorium []Entonibrnent Address IICrernation Queensbury Town,New York Pupation ORemoval Date Place Removed and{or andior Held (F Hold Address N 0 d- Gate Point of f/) transportation C3 by Coinnron Shipment Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/11/2022 Registrar of Vital Statistics �letyaa91/4#("Ekerimni4,,Si net /snatur el 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: i!J t"— ,,,� Z Date of Disposition H�IZ��� Place of Disposition ' 2 (address. ru CC CC foal (lot number! (grave number!O Name of Sexton or Person in Char of Premises 1)) r►�k� Z (p 3se pi inn W Signature f Title Ctav;r,l DO H-1555(07/i8)p 1 of 2 R^}J 6 6 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 1 i Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License# 1