Longo, Roger NEW YORK STATE DEPARTMENT OF HEALTH Of17
Vital Records Section Burial - Transit Permit
Name First .Middle Last Sex
ROGER MICHAEL LONGO Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 13, 2017 68 War or Dates n/a
Place of Death Hospital, Institution or
W City, Town or Village Glens falls, ,NY Street Address Glens Falls Hospital
0 Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Ili Circumstances Investigation
I Medical Certifier Name Title
0
Address
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,„NY 5601
❑Burial Date Cemetery or Crematory
April 17 „2017 Pine View Crematory
❑Entombment Address
gEiCremation Quaker Rd Queensbury,,NY
Date Place Removed
2 Removal and/or Held
9❑and/or Address
i=" Hold
{ Date Point of
03 El Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address •
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford 01443
Address 53 Quaker Road„Queensbury„NY 12804
gli Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ct
to
L Permission is hereby granted to dispose of the human remains d scribed ovedicated.
/ i
li Date Issued 4/�6//2017 Registrar of Vital Statistics �
(signature)
ini District Number ,5-60/ Place city of GLens Falls,,NY
I certify that the remains of the decedent identified above were r�posed of in accordance with this permit on:
ILI 5s r
�,•.c� C./�°�na�Date of Disposition 4///7`/7 Place of Disposition //�'.g--{J
2 ( (address)
Ili
CO
LC (section) i (lot num r) (grave number)
CI Name of Sexton or Per n in harge of Premises J LA- /a v1 4:-W2 he
*fir (please print)
Signature Title C Ce � �
(over)
DOH-1555 (02/2004)