Roth, Gordon NEW YORK STATE DEPARTMENT OF HEALTH-
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gordon Roth Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 5,2013 90 War or Dates ((S W
t. Place of Death Hospital, Institutidn or
Z City, Town or Village Glens Falls Street Address -Glens Falls Hospital
pManner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Shahid Ahmed
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Registerllumber
City,Town or Village Glens Falls 5601
®Burial Date Cemetery or Crematory
August 8,2013 Shaaray Tefila
❑Entombment Address
❑Cremation Main Street,Queensbury,NY 12804
Date Place Removed
G ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ElTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
(]Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
Permission is he eby granted to dispose of the human remains described above as indicated.
Date Issued ?9l3 Registrar of Vital Statistics
(signature).
District Number 5601 PlaCe Glens Falls l/ty 4,1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition _2 Place of Disposition 3r Gam.
W � (address)
CO
c (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises ,i5 ir._--.. L'r -(7
Z (please print)
W Signature Title ju.- ((/Wr
f (over)
DOH-1555(02/2004)