Callahan, Robert OF
1 -4% #71)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert David Callahan M
Date of Death Age If Veteran of U.S. Armed Forces,
10 / 16 / 2017 6 7 War or Dates
14 Place of Death Hospital, Institution or
Z City, Town or Village Providence Street Address 163 Fishback Road
ILI
Q Manner of Death TE Natural Cause ❑Accident ❑Homicide Ei Suicide riUndetermined 1-1❑Pending
tt Circumstances Investigation
j Medical Certifier Name Title
Susan M. Muller MD
Address
119 Lawrence St., Saratoga Springs, NY 12866
:::„,„,,,
Death Certificate Filed District Number 1....6411.4 Register Number 5
City, Town or Village Providence
0Burial Date Cemetery or Crematory
10 / 18 / 2017 Pine View Crematory
El Entombment Address
`: ❑x Cremation 21 Quaker Road, Queensbury, NY
Date Place Removed
�ri Removal and/or Held
and/or Address
C Hold
0 Date Point of
CA Q Transportation Shipment
3 by Common Destination
41 Carrier
;<: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:': Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care I 00364
Address
402 Maple Ave., Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
lit
Permission is h reb granted to dispose of the hums emains des ribed above as indicated.
iiN Date Issued Registrar of Vital Statistics 11v�;
(signature)
District Number �- Place Providence , New York
Fr I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition /D-/9-I "7 Place of Disposition A:Y)w;CAA) e..oe./frie,/0EV
2 (address)
fi3
C (section) ` C4. t number) (grave number)
0 Name of Sexton or r on . Charge of Premises J L.,,,-- L.,,,-/l yi .ivi
(please print)
-- •
til Signature Title C r2 �7��
(over)
DOH-1555 (02/2004)