Caldera, Robert NEW YORK STATE DEPARTMENT OF HEALTH 4t 511
Vital Records Section - Burial - Transit Permit
Name First Middle Last 1 Sex
Robert Caldera ! Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/10/2014 83 yrs. War or Dates Korean War
Place of Death Town of Hospital, Institution or
City, Town or Village Hague I Street Address 23 Pine Orchard Road
• Manner of Death X Natural Cause n Accident —Homicide E Suicide n Undetermined C Pending
•, Circumstances Investigation
Pa Medical Certifier Name Title
lia Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village xagiip 5653
Date ' Cemetery or Crematory
n Burial 09/1 5/201 4 Pine View Crematory
Address
Cremation Queensbury, New York
Date ' Place Removed
Zn Removal and/or Held
nand/or Address
Hold
0 Date Point of
Nn Transportation Shipment
15 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: Address
Permission is hereby granted to dispose of the human remains described above as indi ated.
iN Date Issued 09/12/2 01 4 Registrar of Vital Statistics C n n . (l
ure)
District Number 5653 Place . Town of Hague
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
E Date of Disposition 9��",v Place of Disposition //t/L_ lke. eeil/
2 (address)
LU
CC (section (lot umb r) (grave number)
QAtir Name of Sexton . 'er/ .' ii - .- .f Premises � 0 id
(please print) / A �'
Uil Signature .A) -
vier� _ .� V_ +► Title
(over)
DOH-1555 (9/98)