Roberts, Patricia .. , ,, 11 6 c?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'PyS.w. Patricia L.Roberts Female
Date of Death Age If Veteran of U.S. Armed Forces,
-, 08/31/2017 72 Years War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Ballston Spa Village Street Address Saratoga Center for Rehab and Skilled Nursing
9 P 9 9
- Manner of Death pc,Natural Cause El Accident El Homicide p Suicide rl Undetermined 11 Pending
•x Circumstances Investigation
• Medical Certifier Name Title
'' Jose Nebres MD
rb
Address
149 Ballston Ave,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
,w City, Town or Village Ballston Spa Village 4520 59
"Fri
Burial Date Cemetery or Crematory
AP,; 09/01/2017 Pine View Crematorium
`;. ❑Entombment
Address
glCremation Queensbury, New York
h Date Place Removed
❑Removal and/or Held
and/or Address
lr Hold
Date Point of
Q Transportation Shipment
• ' by Common Destination
Carrier
1❑Disinterment
Date Cemetery Address
_ Date Cemetery Address
Q Renterment
;.,„ Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
0 9 Pine St,Chestertown,New York 12817
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
;fit Date Issued 09/01/2017 Registrar of Vital Statistics �eriLee oconnor Efectronicat61Signed
(signature)
e,gi District Number 4520 Place Ballston Spa Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p p
..:.
Date of Disposition 1 Jc)f Place of Disposition 1'H ULw/ (.-G.et"-1
(address)
w
(section) number) (grave number)
Name of Sexton or Person in Charge of Premises Ieprint)I. 5t'4k
Signature (pl XI
Title (ate nitfj
(over)
DOH-1555(02/2004)