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Williams, Robert M #ni NEW YORK STATE DEPARTMENT OF H EALTH I LO) Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert M.Williams Male Date of Death Age If Veteran of U.S.Armed Forces, 02/19/2023 77 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital W p Manner of Death Ei Natural Cause IllAccident 0 Homicide ESuicide ❑Undetermined ❑Pending W Circumstances Investigation WMedical Certifier Name Title 0 Derek Smith MD Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed City Of Saratoga Springs District Number Register Number City,Town or Village 4501 121 EBurial Date Cemetery,Crematory or Facility Name 02/21/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Q❑Removal Date Place Removed and/or and/or Held ~ Hold Address CO 0 a Date Point of U)❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom . Remains are Shipped,If Other than Above M Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/21/2023 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: l— Z Date of Disposition 2iZz.(Z3 Place of Disposition �..t.L ZF-- W 2 (address) W Cl) (section) (lot number) (grave number) 0 0L 1--1 Name of Sexton or Person in Charge of Premises Z g (lease print) tL Signature ` Title C IP /v)W DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of T delivered on , 20 Pine View Cemetery Representing the funeral home named on burial p-- Official Funeral Directors Reg.or License#