Mitchell, Roy R_ J y
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permi
Vital Records Section
Name First Middle Last Sex
'` _o Roy Mitchell Male
.
Date of Death Age If Veteran of U.S. Armed Forces,
01/12/2018 70 Years War Or Dates 1965-1968
Place of Death Hospital, Institution or
j City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
44 Manner of Death X❑ Natural Cause ❑Accident ❑Homicide ❑Suicide 17❑Undetermined ri❑Pending
-,- Circumstances Investigation
_ Medical Certifier Name Title
Carrie Miron PA
t > Address
170 Warren St,Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 17
El Burial Date Cemetery or Crematory
s.' 01/15/2018 Pine View Crematory
my❑Entombment
Address
, ®Cremation Queensbury Town, New York
Date Place Removed
El❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
,_oo Carrier
• ' Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
E Permit Issued to Registration Number
ll= Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
.- 11 Lafayette St,Queensbury,New York 12804
Ifi
1E
Name of Funeral Firm Making Disposition or to Whom
1'7 Remains are Shipped, If Other than Above
- Address
„_M1
_-, Permission is hereby granted to dispose of the human remains described above as indicated.
cz
3 Date Issued 01/12/2018 Registrar of Vital Statistics Robert Curtis(E(ectronicaf(y Signed)
CA (signature)
-711
ItY 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:
Date of Disposition i ((Ip I g Place of Disposition
,4 C- --1
-- (address)
(section) (lot numb (grave number)
-74
___...JJJ
Name of Sexton or Person in Char a of Premises
(please print)
-_- Signature Title (PIE1411
(over)
DOH-1555 (02/2004)