Roberts, Max ft 3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit ermit
Vital Records Section c
Name First Middle Last Sex
Max Oliver Roberts Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/05/2016 16 Days War or Dates No
I-- Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Albany Medical Center Hospital
d Manner of Death ® Natural Homicide ❑ Undetermined ❑ Pending
U Cause ❑ Accident ❑ ❑ Suicide Circumstances Investigation
0 Medical Certifier Name Title
CI Marilyn Fisher MD
Address
43 New Scotland Ave. Albany, NY 12208
Death Certificate Filed District Number Register Number
City, Town or Village City of Albany 101 981
Date Cemetery or Crematory
❑ Burial 05/09/2016 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
Hold
CO
Date Point of
O Transportation Shipment
CO ❑ By Common
a Carrier Destination
❑ Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. Saratoga Springs, NY 12866
H Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
w, Address
WI
a Permission is hereby granted to dispose of the human remains ' ed above as indicated. / 1
Date 05/06/2016
Issued Registrar of Vital Statistics ����
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition 5 frill. Place of Disposition 1/2/44, rt' 9rt..-.
(address)
2
w (section) lot number) (grave number)
0
' lf
W Name of Sexton or Person in Charge of Premises j rgn� >t w+�'�
(please print) 4
Signature L1 Title CILC MIV�
(over)
DOH-1555 (02/2004)