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Mason, Roger NEW YORK STATE DEPARTMENT OF HEALTH'` Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roger O. Mason Male Date of Death Age If Veteran of U.S.Armed Forces, August 9,2006 83 War or Dates World War II Place of Death Hospital, Institution or Town of Queensbury Westmount Health Care Facility Z City,Town or Village Street Address » Manner of Death © Natural Cause ❑ Accident ❑ Homicide [] Suicide ❑ Undetermined ❑ Pending 0 Circumstances Investigation oMedical Certifier Name Title W Roslyn Socolof Physician Address 100 Broad St.,Glens Falls,NY 12801- Death Certificate Filed District Number Reg+�#er Dumber City,Town or Village Town of Queensbury 5657 ❑ Burial Date Cemetery or Crematory 8/10/2006 Pine View Crematorium ❑ Entombment Address ® Cremation Queensbury,NY Date Place Removed z 0 Removal and/or Held 0 and/or Address F. Hold N Date Point of R ❑ Transportation Shipment N by Common Destination ID Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Alexander Funeral Home,Inc. 00037 Address 4479 State Route 28,North River,NY 12856 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above - Address te d Permission is hereby granted to dispose of the human rem ins cribed abc asMe� Date Issued 08/10/06 Registrar of Vital Statistics w�-s2 y—. (signature) District Number 5657 Place Town of Queensbury Clerk,Town Hall,Queensbury,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I-- WW Date of Disposition c/Ai /bb Place of Disposition P,nov,f ro it oriv,,ti (address) w� (section) lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises L L r's xn n c"-i O (please print)▪ Signature 6/1/itft2 /'Title (� r t4.1%CA-or DOH-1555(02/2004) (over)