Chadwick, Rober Paul Sr. '`�� 1/S 2
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NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle last Sex
Robert Paul Chadwick Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/16/2022 84 Years War or Dates 1958-1964
i_ Place of Death Hospital Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death []Natural Cause DAccident DHomicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
0 Medical Certifier Name Title
C Moiz Ehtesham
Address
43 New Scotland Ave,Albany,New York 12208
Dea9th Certificate Filed City of Albany District Number Register Number
City,Town or Village 0101 2391
Burial Date Cemetery,Crematory or Facility Name
10/181
2022 Pine View Crematory
Entombment Address
Cremation Clueensbury Town,New York
Donation
4:1DRemoval Date Place Removed
and/or and/or Held
t—N Hold Address
0
O. Date Point of
0❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kikner Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward.New York 12828
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Otherthan Above
5 Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/18/2022 Registrarof Vital Statistics ,7.laniegiSgilirprs(S4ctflmicalySign4
(signalurel
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10IigIjL ?Place of Disposition _ t.i}�1�--,
W (address)
W
(ACC (section) 4 (/ot number (grave number)
ft
C Name of Sexton or Person in Charge of Premises f e - {
ase print)
W Signature L Title 1
fiNTAC
DOH-1555(07/18)pi of 2
-116
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral-home named on burial permit
Official Funeral Directors Reg.or License# !`- t '.6..