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Roy, Carl -11 NEW YORK STATE DEPARTMENT OF HEATH, %i. 77(, Vital Records Section Burial - Transit Permit i • Name First Middle Last Sex t Carl Lee"Cajun" Roy Male Date of Death Age If Veteran of U.S. Armed Forces, October 14, 2017 60 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 39 Montcalm Street Manner of Death rn L.Ni Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Christopher Mason, Dr. Address Death Certificate Filed District Number Regisumber f '• City, Town or Village Glens Falls ,-.❑Burial Date Cemetery or Crematory October 18, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 t Date Place Removed ❑ Removal and/or and/or Held Hold Address Date Point of ❑Transportation Shipment by Common Destination Carrier • El Disinterment Date Cemetery Address Date Cemetery Address ❑ Reinterment 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 a Remains are Shipped, If Other than Above Address Permission is herebl granted to dispose of the huma remains described bove as in • - Re istrar of Vital Statistics • Date Issued /v a(j! g L� O:v� - �/' \ .,; 1�, (signature) : District Number Place / tAl a-' - -14 „ /,,k,„ I certify that the remains of the decedent identified above were disposed of in actor nce with this permit on: Date of Disposition 10/18/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (section) art number) (grave number) Name of Sexton or Person in Charge of Pr mises ( �r 3;.# tii- 7) (pl ase print) Signature (i.( Title C , g (over) DOH-1555 (02/2004)