Davis, Robert Fred NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Robert Fred Davis Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/14/2023 70 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 33 Gregwood Circle,Queensbury Town,New York 12804
pManner of Death El Natural Cause Accident ❑Homicide ESuicide Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Thomas Portuese MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 9
Burial Date Cemetery,Crematory or Facility Name
01/17/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
ElDonation
ZO Removal Date Place Removed
and/or and/or Held __
H Hold Address
N
0
O. Date Point of
N❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
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
F. Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/17/2023 Registrar of Vital Statistics Caroline YEaegarteBar6er(ElectronicallySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
—>
Z Date of Disposition I i lcj 13 Place of Disposition
LU
2 (address)
W
CC CC (section) If (lot number) (grave number)
4L._. cat
S Name of Sexton or Person in Charge Premises //A (pa print) /�.�imy�
W Signature Title F pst
DOH-1555(07/18)p 1 of 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#