Roessler, Guenter, H. �
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Guenter Herman Roessler Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/28/2020 86 Years Waror Dates 1956-1962
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Rd,Moreau Town,New York 12803
p Manner of Death 0 Natural Cause Accident Homicide El Suicide Undetermined 0 Pending
W Circumstances Investigation
U Title
W Medical Certifier Name
Madison Zuis NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 7
Burial Date Cemetery,Crematory or Facility Name
01/29/2020 Pine View Crematory
Entombment Address
EjCremation Queensbury Town,New York
Donation
z Removal Date Place Removed
0 and/or and/or Held
F- Hold Address
N
G� Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Registration Number
Permit Issued to
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/29/2020 Registrar of Vital Statistics CeeannMeca&(-YectronkaYS6,=4
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—W Date of Disposition 3d Z 9G Place of Disposition '(a dress/ 6
ft—
(section/ /lot number/ 7—(grave number/
0 Name of Sexton or Person in Charge of Premises
0 /p ase print)
ZZ/
-�
W Signature Title
DO H-1555(07/18)p 1 of 2
! c `
Public Health Law Sec. 4145(2b) Q 1`52 S�
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#