Bradway Sr., Roscoe Erwin NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roscoe Erwin Bradway Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2019 74 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Chester Town Warren Street Address 179 State Route 28 N,Chester Town Warren,New York 12853
W Manner of Death Undetermined Pending
IO Natural Cause ❑Accident ❑Homicide Suicide g
W Circumstances Investigation
V
W Medical Certifier Name Title
Kate Sauer-Jones PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Chestertown 5652 22
Burial Date Cemetery,Crematory or Facility Name
12/12/2019 Pine View Crematory
Entombment Address
RCremation Queensbury Town,New York
Donation
z Removal Date Place Removed
and/or —7and/or Held
H N Hold Address
O
IL Date Point of
U) Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
h— Remains are Shipped,If Other than Above
2 Address
IX
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/11/2019 Registrar of Vital Statistics MthdyConway�_-&tronuag5Soied)
(signature)
District Number 5652 Place Chestertown, New York
1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z `
W Date of Disposition �Z I 12 115 Place of Disposition , J.., "w•-
W /address/
W
N (section) (iotnumber) (grave number)
Q _
Name of Sexton or Person in Charge of Premises �—
Z (pl se print)
W Signature Z Z-4 Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013144,
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#