Doin, Robert Brooke Sr. ULF
JG5J
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records BUrlal - Transit Permit
Name First Middle Last Sex
Robert Brooke Doin Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/13/2022 78 Years War or Dates 1969
I— Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
Ill
• Manner of Death ❑X Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W• Medical Certifier Name Title
O 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 421
Burial Date Cemetery,Crematory or Facility Name
08/15/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
g❑Removal Date Place Removed
- and/or and/or Held
F- Hold Address
CO
0
d Date Point of
(I) Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
E.. Remains are Shipped,If Other than Above
2 Address
LC
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/15/2022 Registrar of Vital Statistics Megan Nouiin(ECectronically Signed)
/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:
2
W Date of Disposition Myr ` �
�1Z Place of Disposition 1
/addr ss/
W
� (section) � `(fot num� (grave number)
O Name of Sexton or Person in Charge of P mi
f' -� ��
\\(please print)/
W Signature _ Title cigfAll�
DOH-1555(07/t8)p 1 of 2
0 1 6 5 8
Public Health Law Sec. 4145(2b)
Receipt
Human remains of 1 delivered on Y , 20
‘4,
Pine View Cemetery Representing the funeral home named onibuyi,a1-9eAnit
Official Funeral Directors Reg.or License# I