Gaynor, Jr. Roger Louis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger Louis Gaynor, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 01 / 2020 76 War or Dates 1963-1967
}- Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address 26 Zephyr Lane
Uj
0 Manner of Death®Natural Cause ❑Accident Homicide Suicide ❑Undetermined �Pending
Circumstances Investigation
0.
Medical Certifier Name Title
Sanjay Taneja MD
Address
294 Grand Ave, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga SpringsLys
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Burial Date Cemetery or Crematory
03 / 03 / 2020 Pine View Crematory
Entombment address
FCremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave., Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 3- _0 2D Registrar of Vital Statistics
(Jignwrer
District Number L4St7 l Place Saratoga Springs New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition to Place of Disposition IL 1,7tvfu—
(address)
(section) (lot number) (grave number)
Name of Sexton or Person 7Che ZfPmises r• �a
(plebse print)
Signature Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) .m
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#