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Caldwell Sr. Royal L. NEW YORK STATE DEPARTMENT OF:HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Royal L.Caldwell Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 04/24/2020 71 Years War or Dates II— Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre `p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Wendy Steinhacker PA Address 1152 Sherman Ave, Queensbury Town, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 79 ❑ Burial Date Cemetery,Crematory or Facility Name 04/25/2020 Pine View Crematory 3❑Entombment Address Cremation Queensbury Town, New York Donation Zlr Removal Date Place Removed O`L-1 and/or and/or Held H Hold A--dress Ni 0' a Date Point of N _ Traruportation by Common Shipment Carrier —�—Destination Disinterment Date Cemetery Address 1 Date Cemetery Address L i Reinterment Permit Issued to Registration Number Name o"Funeral Hor,ie Brewer Funeral Home Inc 00211 Address 24 Church Street PC Box 500, Lake Luzerne, New York 12846 Na re if=uneral Firm Making Disposition orto Whom l— Rer,,,H:,are Shipped,ii Other than Above Address lx W----- a', Pa. fission is hereby granted to dispose of the human remains described above as indicated. Date Icsl,ed 04/24/2020 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) Distiia Number 5657 Place Queensbury, New York f certi y :rear the remains of toe decedent identified above were disposed of in accordance with this permit on: 1H W' Date s�.')isposition Ll/11110 Place of Disposition f p fiu,�, (address) W (section) (lot number) (grave number) W. © Name of Sexton or Person in Charge of It /� / (p!e e print) ^ A' � Signature Title 6 t DJ 1-1 5 5? ;--7!18)p 1 of 2 `tl q '�, Public Health Law Sec. 4145(2b)- A Receipt Human remains of delivered on , 20— t Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#