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Keator, Robert K NEW YORK STATE DEPARTMENT OF HEALTH 4_ C•1.1.6 Burial - Transit P1rmit Bureau of Vital Records Name First Middle Last Sex Robert K Keator Male Date of Death Age If Veteran of U.S.Armed Forces, 02/06/2023 77 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Kingsbury Town Street Address 1940 Sanford Ridge Road,Kingsbury Town,New York 12804 0 Manner of Death ❑X Natural Cause Accident III Homicide ESuicide nUndetermined ElPending W U Circumstances Investigation W Medical Certifier Name Title G John Quaresima MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Kingsbury District Number Register Number Ci ,Town or Village 5762 4 Burial Date Cemetery,Crematory or Facility Name 02/08/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation O❑Removal Date Place Removed c and/or and/or Held Hold Address 0 Date Point of N❑Transportation Shipment ES by Common Carrier Destination O Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom 1• Remains are Shipped,If Other than Above 2 Address CC W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2023 Registrar of Vital Statistics Cynthia Bardin(Electronically Signed) (signature) District Number 5762 PlaCe Town Of Kingsbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition Z 19 1 Z3 Place of Disposition � �ti v&r (address) W CC (section) / (tot number) (grave number) O Name of Sexton or Person in Charge of Pr mises !`�'r (" 14-il it Q ease print) Zc4 6r.,9m�Tr�l2 W Signature Title 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#