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Defoe, Roger if (f NEW YORK STATE DEPARTMENT OF HEALTH f Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roger Lloyd Defoe Male Date of Death Age If Veteran of U.S. Armed Forces, June 2, 2018 84 War or Dates Place of Death Hospital, Institution or LL City, Town or Village Street Address Albany Medical Center Q Manner of Death mNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title G Nicholas J. Russo, Address 43 New Scotland Ave Albany, NY 12208 Death Certificate Filed District Number Register Number City, Town or Village I 130 ❑Burial Date Cemetery or Crematory June 5, 2018 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held a and/or - Address Hold Date Point of a. Transportation Shipment by Common Destination O Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped, If Other than Above 2' Address LLt11,' Permission is hereby granted to dispose of the human remains de 'bed above as indicated. Date Issued O/c J2O12 Registrar of Vital Statistics (signature) District Number UFO Place G Of A` nj ▪ I certify that the remains of the decedent identi above were disposed of in accordance with this permit on: W Date of Disposition 06/05/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W EZ (section) f lot number) (grave number) O Name of Sexton or Person in Charge of Premises (4 (ple8se print) W Signature Title (Pf' h TOIL. (over) DOH-1555 (02/2004)