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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robin S.Larsen Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/20/2022 61 Years War or Dates
H Place of Death Hospital,Institution or
�Z City,Town or Village Mount Pleasant Town Street Address Westchester Medical Center
Manner of Death I INaturalCause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Syed Rahmatullah MD
Address
100 Woods Road,Mount Pleasant Town, New York 10595
Death Certificate Filed Town Of Mount Pleasant District Number Register Number
City,Town or Village 5957 898
Burial Date Cemetery,Crematory or Facility Name
11/23/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
g❑Removal Date Place Removed
and/or and/or Held
f- Hold Address
CO
0
Date Point of
U)❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
ri
Reinterment
Date Cemetery Address
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
f... Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/22/2022 Registrar of Vital Statistics `Emily Costanza(Electronically Signed)
(signature)
District Number 5957 Place Town Of Mount Pleasant
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z Date of Disposition //—ZS--Z'2 Z. Place of Disposition r,�e JJ).r 2„tJ �� ,qy--6 r
W /addre3
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N (section) (lot number) (grave number)
IX
Name of Sexton or Person in Charge f Pre i �t4 ,.-nr J�
Z ci
(please print)
tL / / Title 0 f-`�,: r
Signature
DOH-1555(07/18)p 1 of 2
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#
InF
Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Robin S. Larsen
were cremated on November , 25 20 22 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death November , 20 20 22 Age 61
(Month) (Day)
Funeral Home Carleton Funeral Home Registered No. 920
(Authorized Signature)
LARSEN ( LF )
Robin Larsen Age: 61
Lot Owner: Marcus & Robin Larsen
Lot# Algonquin 107 C Grave# 4
Case: Urn
Died: 1 1 .2 0.2 2 Interred: 1 2.1 .2 2
Funeral Home: Carlenton FH
Cemetery: Pine View
Owner ll
Marcus Larsen/ DiN !4PSCA/
Address Plot
153 Broad St _ Apt_ SS Hnr1Snn Pall , Ny 12839 Algonquin
Phone # Lot #
518-409-8879 107C
Deed # Date
4169 4/10/2020
Cost Foundation Y - N
$350.00 + $400_00 +$15n On R R_ -$900_nn
Location
North--Vacant
South--Road `a_cc� s
East--Vacant 1
West--Road
Remarks
I ACKNOWLEDGE THE RECEIT OF THE RULES AND REGULATIONS OF
PINE VIEW CEMETERY.
SIGNATURE: 6 DATE: CU 7 Ci
Record of Interments
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