Roth, Alfred NEW YOP'IK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alfred R. Roth Male
M. Date of Death Age If Veteran of U.S. Armed Forces,
,;� December 31, 2012 83 War or Dates
'7 Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Orchard Nursing & Rehab Center
• Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined Pending
la Circumstances Investigation
Medical rtifier Name Title
91 Sean Kimba Cell,DO
• ' Address
�<>< 79 North Street,Granville,NY
Death Certificate Filed District Number���� Register Number
tg City, Town or Village Granville I
Burial Date Cemetery or Crematory
❑Entombment January 7, 2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
! Hold
CO
O Date Point of
W ❑Transportation Shipment
a 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
',,N Address
53 Quaker Road, Queensbury,NY 12804
j Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
E Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 114 Ovo Registrar of Vital Statistics ‘� —
(signature)
District Number �J75-6 Place Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1 /7/1 3 Place of Disposition Pine View Cemetery
W (address)
co Seneca 1 8F 1
re (section) (lot number) (grave number)
Q Name of Sexton or Perso in Charge of Premises Michael Genier
Z _ _ (please print)
LIJ
Signature �/w«\. Title Superintendent
(over)
DOH-1555(02/2004)