Callahan, Brian NEW YORK STATE DEPARTMENT OF HEALTH ft Z T1,
Vital Records Section i N. Burial - Transit Permit
3 Name First Middle Last Sex
Brian V. Callahan Male
Date of Death Age If Veteran of U.S. Armed Forces,
` June 6, 2011 67 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley Health Center
mg Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
151 Circumstances Investigation
I Medical Certifier Name Title
ro
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number 5_7 Register Number 33
City, Town or Village
,eyft4 ❑Burial Date Cemetery or Crematory
June 8, 2011 Pine View Crematory
:tt,'',,i
❑Entombmenttti. .. Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑
Removal and/or Held
- and/or
Hold Address
v'eDate Point of
nTransportation Shipment
I by Common Destination
Carrier
F
tt El Disinterment
Date .Cemetery Address
❑ Reinterment Date Cemetery Address
iirle Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01096
a Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
Permission is h reby granted to dispose of the human remai esc ibed a as indicated.
Date Issued ( Registrar of Vital Statistics
�� (signature
District Number 5 W Place ; b1.13n 0--C. af,
y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
', Date of Disposition 06/08/2011 Place of Disposition Quaker Road Queensbury,NY 12804
t. e (address)
(section) + (lot nu�) (grave number)
: ' Name of Sexton or rson in C rge of Premises not r Jlhnil}
(please print)
Signature C2rp) d g.
� 9 Title � ��
(over)
DOH-1555 (02/2004)