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Sheldon, Robert NEW YORK STATE DEPARTMENT OF HEALTH '- - s TI ,3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert D. Sheldon Male Date of Death Age If Veteran of U.S. Armed Forces, November 21, 2016 80 War or Dates - Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home ' Manner of Death .J Natural Cause IIIAccident ❑ Homicide ❑ Suicide ElUndetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Philip J. Gara, Dr. Address 318 Broadway Fort Edward 12828 Death Certificate Filed District Numb 55 Register Number %-7 City, Town or Village Fort Edward 0 Burial Date Cemetery or Crematory November 23, 2016 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed I. Removal and/or Held and/or Address Hold Date Point of Transportation Shipment by Common Destination 0 Carrier Date Cemetery Address ❑ Disinterment Reinterment Date Cemetery Address - Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address a, Permission is he eby ranted to dispose of the human 'ns descrH21d ab e i icated. Date Issued Registrar of Vital Statistics 6-(M ,----, (signature) District Numbers') 5 Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 11/23/2016 Place of Disposition Quaker Road Queensbury,NY 12804 1 (address) CO Er (section) (lot number) (grave number) t Name of Sexton or Person in Charge of Premises 111404 li✓ S440 zz (p/ ase print) W Signature a 4 Title «Ohara " (over) DOH-1555 (02/2004)