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Bishop, Roderick NEW YORK STATE DEPARTMENT OF HEALTH l R3c Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roderick Irwin Bishop Male Date of Death Age If Veteran of U.S. Armed Forces, 9/29/2017 91 War or Dates Navy i_ Place of Death Hospital, Institution or 'Z City, Town or Village Queensbury, NY Street Address 27 Woodvale Road p Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending V Circumstances Investigation w Medical Certifier Name Title G Karen Zanni,FNP Address Glens Falls,NY Death Certificate Filed District Number Register Number City, Town or Village Queensbury,New York 5657 La ❑Burial Date Cemetery or Crematory October 3, 2017 Pine View Crematorium C Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed Z I I Removal and/or Held and/or Address N Hold co a Date Point of N ( !Transportation Shipment p by Common Destination Carrier I Disinterment Date Cemetery Address I Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road,Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above 2 Address Ce W O. Permission is hereby granted to dispose of the human e ains describe above as indicated. Date Issued l(`) �1I� Registrar of Vital Statistics w y^ —��. (,- (LA._--- (signature) C"... District'Number�(s;S'--) Place I U � - �� � I certify that the remains of the decedent identified above were disposed of in acc rdance ith this permit on: WDate of Disposition /p '3 I n Place of Disposition ekti ;,.. illovvatefpie. W (address) U) re (section) (lot number) (grave number) p Name of Sexton or Person in Charge of Premises (11 '&A'..— ci.,44:0 Z (p ase print) W /� Signature l✓t I� Title /�t (A' � (over) DOH-1555(02/2004)