St. John, Roy J. .•
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NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roy J.St John Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/25/2020 75 Years War or Dates
l— Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
ILI
• Manner of Death Ei Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑Pending
lL Circumstances Investigation
W Medical Certifier Name Title
O along Wang MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 505
Burial Date Cemetery,Crematory or Facility Name
09/28/2020 Pine View Crematory
Entombment Address
X❑Cremation Qileensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
• Hold Address
0
d
U) Transportation ~Date Point of
p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/28/2020 Registrar of Vital Statistics join Pau19ranck(Electronica(Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l—
Z Date of Disposition 1 i Z9 t 70 Place of Disposition .../(.
(address)
W
CC CC (section) (lot number) (grave number)
O ill �pA 4ll�
0 Name of Sexton or Person in Charge oo, emises
Z L'-J /� (pie a print) /
W 11(11124
Signature Title `
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1 4 0 5 7
Receipt
Human remains of / ' delivered on , 20.,
Pine View Cemetery Representing the funeral home named oji permit
Official Funeral Directors Reg.or License#