Marshall Sr., Roy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.
„A` Name First Middle Last Sex
tiki
Ro Raymond Marshall Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2011 69 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 129 North Street
Manner of Death Natural Cause 0 Accident Homicide El Suicide riUndetermined El Pending
Circumstances Investigation
al Medical Certifier Name Title
Joseph C. Mihindu, MD,
Address
RO
20 Murray Street Glens Falls, NY 12801
Op Death Certificate Filed District Number Register Number
City, Town or Village 5'742 9 O 9
Date ,n„�� (7 ! 7 // Cemetery or Crematory
®Burial V"r / ,to C�
r � Pine View Cemetery
Entombment Address
J ['Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
' ,; Removal and/or Held
and/or
Hold Address Pine View Cemetery
,171 Date Point of
Transportation Shipment
by Common Destination
' Carrier
-044 0Disinterment Date Cemetery Address
,,..- Reinterment Date Cemetery Address
„0,4
Permit Issued to Registration Number
,f Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
-` 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 indicated.
,,, Date Issued `1 ant( Registrar of Vital Statistics a,i4d.a_. CG
(signature)
District Number �,�'r]G a Place `-1-; ,.— i r
.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 5/26/11 Place of Disposition Pine View Cemetery
(address)
Erie 4F 1
(section) (lot number) (grave number)
Name of Sexton or Perso 'n Charge of Premises Michael Genier
Superin(ten tint)
Signature `' Title
(over)
DOH-1555 (02/2004)