Roemer, Jane JR
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
f/7 Name First Middle Last Sex
Jane Roemer Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 14, 2016 86 War or Dates
%; Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center
Manner of Death Undetermined PendingJatural Cause n Accident U Homicide ❑Suicide ❑
Circumstances Investigation
Medical Certifier Name c 0 '� 2 Title 0
Address )3 I La w Ci e n crc J 1 St,oa,t V(. 0 z i t t iq . LU I i CL
• Death Certificate File District Number Register Number
Cit Town or Villag ,}''O. a�n n �'5, 2.4?)
Date Cemetery Burial or Crematory
Wednesday, May 18, 2016 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road Queensbury, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
O.
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
'' Address
'' 53 Quaker Road, Queensbury,NY 12804
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I::
Ui
▪ Permission is here y granted to dispose of the human remai cried afe a indicate .
c
• Date Issued h I �� Registrar of Vital Statistics °
(signature)
• District Number 45c1iPlace $c,.xotr'ie pr
( S
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 5/1 8/1 6 Place of Disposition Pine View Cemetery, Queensbury,NY
W (address)
co Mohawk 124 2
re (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie L. Goedert
W
(please print)
Signature (1, 4.,_-, f.J,
r---- Title Cemetery Superintendent
(over)
DOH-1555(02/2004)
I