Sullivan, Robert RX Date/Time 06/18/2018 07:3i 1„ 85844843 P•001
Jun.18.2018 09:01 AM COMPASSIONATE FUNERAL CAR 15185844843 PAGE. 1/ 1
It In
NEW YO K STATE DEPARTMENT OF HEALTH '
Vital Rec rds Section Burial - Transit Permit
Name First Middle. Last Sex
• Robert Sullivan :Male
Date o Death Age If Veteran of U.S.Armed Forces,
:1; 06/13/20 8, 78 Years War or Dates 1969-1961
•;. Place of Death Hospital, Institution or
st City,.Town or Village Saratoga Springs 'rest Address Wesley Health Care Center Inc
Manner of Death Q Natural Cause 0 Accident riomicide [l Suicide (l Undetermined. a Pending '
to Circumstances lnvestgation,
'if. Medical Certifier Name M Title •
_ , . Eric Sontag NP • .
ri Address .
T. 131 Lawr nce St,Saratoga Springs,New York 12866
Death certificate Filed District Number Register Number '
,..',1 City,To nor Village swains Sprtcngs .4501 . ' •,.339
OBurial Date Cemetery or Crematory - •
06/18/2018 Pine View Crematory
'^ ❑Entom•ment—
w Address •
1' Egerema ion Queensbury Town, New York ' ` '
Date Place Removed - • '
Rem•val and/or Held
�' "'and/0 Address
Hold
,YP.—
9 Date Point of
°'` 0 Trans'•rtation Shipment
r.1 —
;, by Co mon Destination
Carrie
s ' Date Cemetery Address
u Disint:rment
r,' ID Reinte ment Date Cemetery Address
ue Permit is:ued to Registration Number i
'1. Name of uneral Home Compassionate Funeral Care Inc ,00364
' Address
402 Maple •ve,Saratoga Springs,New York 12886
1 Name of uneral Firm Making Disposition or to Whom
„r' Remains :re Shipped, If Other than Above
Address
nr
"` Permissl•n le hereby granted to dispose of the human remains described above as indicated.
i° Date issu:d 06/17/2018 Registrar of Vital Statistics Sohn(1'e'ranck('1EfectrorucalrySigned)
1 1 (signature)
,Yi District N mber 4501 Place Saratoga Springs, New York
'?,,, 1 certify that the remains of the decedent identified above were disposed of inin accordance�� with�" this permit on:
fo
rk Date of Di=position iit►s Place of Disposition 1t�tL 6r�wtw-q,
(address)
Ti •
1 (section) t number) (grave number)
0' Name of ,exton or Person in Charge of em►ses
AG�" ��
si
G'�
i
(plea a print)
Signature Title t
(over)
DOH-1555(02 2004)