Lasell, Robert D. Sr. (.1......F) 41
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert D Lasell Sr Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/09/2022 87 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
O Manner of Death ]Natural Cause Accident El Homicide [IISuicide []Undetermined Pending
W U ' 'Circumstances Investigation
W Medical Certifier Name Title
C Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 540
HBurial Date Cemetery,Crematory or Facility Name
09/13/2022 Pineview Crematory
Entombment Address
]Cremation Queensbury Town,New York
0Donation
ZO❑Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
O. Date Point of
(I)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
Q
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/12/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 9 113177 Place of Disposition .F„PV._ .. for
ILI (address)
W
NLC (section) (lot numbers (grave number)
0 Name of Sexton or Person in Charge of Pr ises A ki � '�
Z ( ase print)
W Signature Title rt 4rflgi �
g
DOH-1555(o7/18)p t of 2
4
e..
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on 1 . , 20'
Pine View Cemetery Representing the funeral hon-a-nafned on burial permit
Official Funeral Directors Reg.or License#