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Birkheimer, Robert I . 1 NEW YORK STATE DEPARTMENT OF HEALTH , Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert Blair Birkheimer Male Date of Death Age If Veteran of U.S. Armed Forces, February 17, 2017 55 War or Dates Place of Death Hospital, Institution or W City, Town or Village Hudson Falls Street Address 6B Weston Street WManner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation III Medical Certifier Name Title CI Charles Yun, MD Address Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village <23 ❑Burial Date Cemetery or Crematory February 22, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Pine View Crematorium Date Point of ct. ❑Transportation Shipment by Common Destination Q Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above M Address W'' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 4. ,/ A''(/ 7 Registrar of Vital Statistics (signature) District Number `. - ' : Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i j,y Date of Disposition 02/22/2017 Place of Disposition Quaker Road Queensbury,NY 12804 c (address) Cl) c. (section) , (lot number) (grave number) Name of Sexton or Person in Charge of Premises 9 (ple'se print) Ili Signature C-� -- Title (r;'kMA-(111 (over) DOH-1555 (02/2004)