Rogers, William NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Per it
Name First rr � Middle Last S
1tiJ1 LG> M N PS 1-U S U U S C� �S J G � �j,(1-
Date of Death] / ' Age 1 If Veteran of U.S. Armed Forces,
70 J 9//0 `) , [ War or Dates 1 7 Y Z — / 9 /
1-r Place of Death i Hos•ital Institution or
Cit, Town or Village LW' s y treet Address 3 Till it E� Q.--
jQ , :nner of Death �r U Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Address
1 ( l C, 4 a06_6fAn Q /V ii oY
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Filed Ali trict Number _ � R6gist r Number,
City,, own or Village Lt;' j Fes,,J i )C)i 1 `f
❑Burial Date 2 1/7 Y Cemetery arem of j I
❑Entombmenti / 2pi,),,,,
tJ �'^�
+ Address �'n
Cremation I L U �i . !'i - so, U AJS(3 .
I Date ; Place Removed /`
Z ri Removal
and/or i � and/or Held
t Hold Address
0 I Date ` Point of
N0 Transportation Shipment
CI by Common Destination
Carrier
El
Disinterment Date I Cemetery Address
+
Reinterment Date 1 Cemetery Address
t
Permit Issued to Baker Funeral Home I Registration Number
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Fr Remains are Shipped, If Other than Above
a Address
it
Ui—
a' Permission is hereby granted to dispose of the human remains ascribed�/#ove dicated.
Date Issued o9 , %
o/? Registrar of Vital Statistics -: 4 --
/ (s+ nature)
District Number 54,0/ Place / l/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Wig Date of Disposition %ZS(C1 Place of Disposition _ 12/..4V--.../
W (address)
CC (section) number} (grave number)
p Name of Sexton or Person in Charge of Pr mises ,flol._
- "....4,-
Z � g (ptse print
W Signature G..f e�=•,r Title ntyU,/t-
4'
(over)
DOH-1555 (02/2004) •