Roberts III, Edward NEW YORK STATE DEPARTMENT OF HEALTH ` _ ` ' # f L
Vital Records Section Burial - Transit Permit
Name FiErtkvard Middle Sexkarts lii Semale
l r2g/R1/th A If Veteran of U.S. Armed Forces,
years War or Dates
lor Plac • •-Ow Hospital, Institution or
City, :A ' dt'�/ile Schenectady Street Address Ellis Hospital
a Manner of Death Natural Cause El Accident D Homicide D Suicide 0Undetermined El Pending
la Circumstances Investigation
W Medical Certifier Name Title
Mlroslav Vytrisal M D
i°I1*Nbtt St, Schenectady, N Y 12308
Deat if led Schenectady District
i tri t Number Register Number
460City, o1e 8
❑Burial Date03/03/2017 Cemetery n iw Crematory
❑Entombment Ad drri own Of Queensbury, N Y
❑Cremation
Date Place Removed
2 Removal and/or Held
— and/or Address
Hold
fit))
Date Point of
iii❑Transportation Shipment
a by Common Destination
Carrier •
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to M. B. Kilmer Funeral Home R01'079 tion Number
Name of Funeral Home
El Addr±broadway, Fort Edward, Ny 12828
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
Lu
f` Permission is hereby granted to dispose of the human remains escribed a ve as indicated.
Date Issued 03/02/2017 Registrar of Vital Statistics ?
(signature)
District Numbef601 Place Schenectady
:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
>a Date of Disposition 31i 1 l Place of Disposition, • eN a.J A .Zrr^Cit(k....
(address)
ILI
CC (section) /(lot number) ( (grave number)
0
ta Name of Sexton or Person in Charge of Pr mises al.- ihin'
j� (pl se print)
Signature /f/(( ��(/Y_) Title (WOW—
(over)
DOH-1555 (02/2004)