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Roberts, Timothy „A i t uEPARTMENT OF HEALTH1 # 3,1 Vital Records Section Burial Transit Permit Name First Middle Last Sex Timothy David Roberts Male Date of Death Age If Veteran of U.S. Armed Forces, May 25, 2015 61 War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 27 McIntyre Street Manner of Death 0 Natural Cause n Accident El Homicide El Suicide El Undetermined 111 Pending Circumstances Investigation Medical Certifier Name Title Mark Toma, Dr. Address 47 New Scotland Avenue MC 41 Albany,NY 12208' Death Certificate Filed District Nun - 1o` Registlumber yiri Ci , Town or Village Fort Edward Burial Date Cemetery or Crematory May 28, 2015 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 N Date Place Removed p Removal and/or Held and/or Address Hold Y Date Point of M1`:;• LI Transportation Shipment _ by Common Destination Carrier 51. 1 Disinterment Date Cemetery Address kl, Date Cemetery Address 0 Reinterment 4 Permit Issued to Registration Number LO Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 tto Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is ereb granted to dispose of the human r s de��crriyi ��ed a o e indicated. Registrar of Vital Statistics U�.ti.l(� Date Issued Q '�' ��� 6 CJV-W�(signature) } District Number 61 Sb Place �' M 51 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i ,ti Date of Disposition 05/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) lot number) (grave number) -, Name of Sexton or Person in Charge of Premises - r-` > (plerase print) V cric-Aviv Signature L- ` Title (over) DOH-1555 (02/2004)