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Gardner, Robert Wellman
C- * # (7 NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Per Bureau of Vital Records rnit Name First Middle Last Sex Robert Wellman Gardner Male Date of Death Age If Veteran of U.S.Armed Forces, 01/01/2024 102 Years War or Dates 1942-1945 H Place of Death Hospital,Institution or W City,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803 p• Manner of Death a Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending 0 Circumstances Investigation UJ Medical Certifier Name Title al Madison Zuis NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 2 RBurial Date Cemetery,Crematory or Facility Name 01/03/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held F- Hold Address U) 0 d Date Point of U) Transportation p by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address 0 Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above rd Address CC W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/03/2024 Registrar of Vital Statistics Brenda Rutter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition )I S 01 Place of Disposition r?ef✓i J P�,^14t,d£r-t*1''6 a (address) 11J NCC (section) (lot number) (grave number) 0 /7 e. ntnlf) 0 Name of Sexton or Person in Charge of Premises z IL_ease prin W Signature P Title ..../.4---- 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#