Mitchell, Robert William '
NEW VORKSTATE DEPARTMENT OF HEALTH 'f10 -Burial Transit Permit
Bureau of Vital Records `
Name First g,,Middle Last Sex
Robert William Mitchell Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/24/2022 93 Years War or Dates 1951-1953
1,,, Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
W Manner of Death Undetermined Pending
tp a Natural Cause Accident Homicide Suicide Circumstances Investigation
W Medical Certifier Name Title
0 Madison Zuis NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
4562 48
City,Town or Village
RBurial Date Cemetery,Crematory or Facility Name
08/26/2022 Pine View Crematory
Entombment Address
OCremation Queensbury Town,New York
Donation
Date Place Removed
Q El Removal and/or Held
1 and/or
N
Hold Address
0
Date Point of
N ETransportation Shipment
0 by Common
Carrier Destination
Disinterment
Date Cemetery Address
0 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
1— Remains are Shipped,If Other than Above
M Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/26/2022 Registrar of Vital Statistics Leeann McCabe(ECectronically Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition e-,,,2.7.•y01, Place of Disposition pi Nt, IA-till (.1"-glorY
(address)
W
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises ,t.fr k Y S V" r`'S
(please print)
Z
W Signature G� Title �""` /�r7 r
DOH-1555(o7/18)p 1 of 2
a '. ;1 ' ,
Public Health Law Sec. 4145(2b) =
Receipt
k Human remains of , L.:s delivered on , 20
'
Pine View Cemetery Representing the funeral home,alamed on burial permit
Official Funeral Directors Reg.or License# i