Caulin, Ronald II 3
NEW YORK STATE DEPARTMENT OF HEALTH 3 11
Vital Records Section Burial - Transit Permit
ini Name First Middle Last Sex
Ronald D. Gsttlw - 1'�t j(,,i) Male
ipii Date of Death Age If Veteran of U.S. Armed Forces,
igiii 05/20/2017 83 years War or Dates 1952-1955
'- Place of Death Hospital, Institution or
City, T917 y 1 Glens Falls Street Address Glens Falls Hospital
Manner of Death�,Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ia Circumstances Investigation
iii Medical Certifier Name Title
Howard E Silverberg M. D.
Address
ni 318 Broadway Fort Edward, N Y 12828
iiiN Death Certificate Filed District Number Register Number
City, TWOCO-'(LK)t ( Glens Falls 5601 278
['Burial Date Cemetery or Crematory
❑Entombment 05/22/2017 Pine View Cemetery
iiiAddress
s[,Cremation. Queensbury, NY '' '4
Date Place Removed
Removal and/or Held
and/or Address
H Hold
to
0 Date Point of
CLEITransportation Shipment
is by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01078
Address
82 Broadway Fort Edward, N Y 12828
EI Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
ILA
tL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/22/2017 Registrar of Vital Statistics (N ck,'vr',`Q. (A)
�re)
gg District Number 5601 Place Glens Falls, 'k) U
ii:M I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
t
Date of Disposition SlLtii'�Place of Disposition �, a„1 01•9.
(address)
tii
CC (section) (lot number) (grave number)
fa Name of Sexton or Person in Charge of Premises at4 r.�t ti-
z (phase print)
Signature /1 Title Ctitabiat 1)4_
(over)
DOH-1555 (02/2004)