Wilcox, Roger NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger Wilcox male
Date of Death Age If Veteran of U.S. Armed Forces,
mi
April 17, 1998 _ 74 War or Dates no
)44 Place of Death Hospital, Institution or
• City,_Town or Village Town of Queensbury Street Address Hallmark Nursing Centre .
Ili—Manner of Death IT Natural Cause Eil Accident ❑Homicide El Suicide El Undetermined 0 Pending
l :1 _ Circumstances Investigation_
Medical Certifier Name Title
c Richard Spitzer MD
Address
<» 55 Sheridan St. , Glens Falls, NY 12801
Death Certificate Filed Town of QueensburyDistrict Number _ Register Number
City, Town or Village ,- jp 5 '7 .: 3�
Date Cemetery or Crematory
Burial April 20, 1998 Pine View Cemetery
Address
::::: ❑Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
r- and/or Address
F..... Hold
to
Q Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiSi Permit Issued to Registration Number
Name of Funeral Home Regan and Denny Funeral Service 01565
iii[> Address
iii3 53 Quaker Road, Queensbury, Ny 12804
"'''; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
idg Address
M
a
iiiiiiii Permission is hereby granted to dispose of the humarwenrains desc ' a o as indicated.
iiiiii Date Issued 4-,).1,) J Registrar of Vital Statisti s a--i 0 (, .,4_,(
nature)iBii !�
Place t,�.� - , I . _
Districtiiin Number �tQ�� ��---- "/ ,�-�'�
I certify that the remains of the decedent identified abov were disposed of in accord nce wi this permit on:
Date of Disposition 4/20/98 Place of Disposition ine View Cemetery ,Queens bury ,NY
(address)
MI
Mohican 12-7, 1
CA (section) (lot number) (grave number)
GName of Se . . Person in Ch a of Premises Rodney G. Mosher
g y/ /-j (please print)
t4 Signature _ ,2:- .-- -- J , 'C 061. _ Title Superintendent
DOH-1555 (10/89) p. 1 of 2 VS-61