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Jones, Roger E. NEW YORK STATE DEPARTMENT OF HEALTH /• Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Roger E.Jones Male Date of Death Age If Veteran of U.S.Armed Forces, 03/28/2020 89 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pI Manner of Death © Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending C.) Circumstances Investigation W Medical Certifier Name Title Michael Miles MD Address 112 Ski Bowl Rd,Johnsburg Town, New York 12853 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 151 Burial Date Cemetery,Crematory or Facility Name 04/01/2020 Pine View Crematory Entombment Address MV low i Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held f-N Hold Address O IL Date Point of UA ❑Transportation p by Common Shipment 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 �— Remains are Shipped,If Other than Above Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/01/2020 Registrar of Vital Statistics &bertAndrewCurtis(ECectronicallySiyned) (signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition N/I Z6 Place of Disposition E4 LUj two Uj (address) W N (section/ (lot number) C (grave number) 8 Name of Sexton or Person in Charge of Premises Z /,� (p!ase print) W Signature �✓ Title ��-- DOH-1555(o7/18)p 1 of 2 r i Public Health Law Sec. 4145(2b) 3491 3 Receipt Human remains of delivered on , 20 {, ff ;t t Pine View Cemetery Representing the funeral home named on burial ermit Official Funeral Directors Reg.or License#