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NEW YORK STATE DEPARTMENT OF HEALTH -_ -� Burial - Transit Permit
Bureau of Vital Records
Name First Middle .- Last Sex
Robert Francis Locke Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/17/2023 64 Years War or Dates 1978-1981
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
p Manner of Death ri Natural Cause []Accident ri Homicide Suicide []Undetermined []Pending
W ' 'Circumstances I 'Investigation
U
W Medical Certifier Name Title
CI 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 40
BurialF
Entombment Date Cemetery,Crematory or Facility Name
01/20/2023 Pine View Crematorium
Address
[]Cremation Queensbury Town,New York
Donation
ZZ ElRemoval Date Place Removed
and/or and/or Held
H N Hold Address
0 •
4. Date Point of
(1)[]Transportation
p by Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
— Date Cemetery Address
Reinterment
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
1— Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/20/2023 Registrar of Vital Statistics 'Megan Noliin(Electronically 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:
I-
W Date of Disposition /--�t.Z3 Place of Disposition TPae 44) Crean / r
2 (addre
w
CD
CC (section) // (lot numbed (grave number)
0 Name of Sexton or Person in Charge of emisesIQ7h?!?n1� �l�C'
Z (please print)
Ill -- _---
Signature G Title Qt
DOH-1555(07/18)p 1 of 2
016621
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 24
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#