Mulcahy, Robert NEW YORK STATE DEPARTMENT OF HEALTH %.- ii s Zc
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Emmitt Mulcahy Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 28, 2016 84 War or Dates
1-- Place of Death Hospital, Institution or
W' City, Town or Village Queensbury Street Address 557 Ridge Rd.
WManner of Death n Natural Cause Accident Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman, M.D.
Address
3767 Main Street Warrensburg, NY 12885
Dea rtif ate ' r� District Numt�er R is er Number
Ci , Town or V,, , .a c-- l4 n
❑Burial r3'oa Cemetery or Crematory
--A , 2016 Pine View Crematorium
❑Entombment Address
®Cremation Quaker i d Q eensbury,NY 12804
Date Place Removed
z Removal __ and/or Held
and/or Address
E Hold
0) Date Point of
pa„ ID Transportation Shipment
U) by Common Destination
Ct Carrier
Disinterment Date Cemetery Address
Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. 0. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I-, Remains are Shipped, If Other than Above
E' Address
W:-
0: Permission is ereby granted to dispose of the human re "us described abomas,hqdicatad.
Date IssuedcUl Registrar of Vital Statistics �C� g , /1-c-,�
(signature)
District Number 5(6'") Place 10 C ' N a--cQ_ .
I certify that the remains of the decedent identified above were disposed of in actor nce 'th this permit on:
1r-:
W''' Date of Disposition 04/01/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
0r
it (section) 4j(lot numb (grave number)
0_ Name of Sexton or Person in Charge of Prem. es rta i 14
Wlease print)
Signature a Title r Dvi-
(over)
DOH-1555 (02/2004)