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Wood, Robert L NEW YORK STATE DEPARTMENT OF HEALTH 4...--F) Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert L Wood Male Date of Death Age If Veteran of U.S.Armed Forces, 02/04/2024 84 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing p Manner of Death El Natural Cause Accident Homicide nSuicide nUndetermined ❑Pending I' ('Circumstances Investigation W Medical Certifier Name Title CI Mikram Jafri MD Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 22 + Burial Date Cemetery,Crematory or Facility Name . 02/08/2024 Pineview Crematory Entombment _ _ Address ©Cremation Queensbury Town,New York Donation (S❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 W Date Point of Cl)❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address Q uJ a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/06/2024 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (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: I— W Date of Disposition Z f 1 t14 Place of Disposition �a'✓ W (IC WO, 2 (address) W NCC (section) /1 (lot numbed (grave number) aName of Sexton or Person in Charge of Premises F� Z ell /lease print) W Signature Title kiAffne DOH-1555(07/18)p 1 of z Public Health Law Sec. 4145(2b) t I 1 ! Receipt Human remains of delivered on , 20 1 4 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#