Langworthy, Roger NEW YORK STATE DEPARTMENT OF HEALTH j � I
Vital Records Section Burial - Transit Permit
• ' Name First Middle Last Sex
Roger Emmett Langworthy Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 20,2017 76 War or Dates
:• Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
At Circumstances Investigation
W Medical Certifier Name Title
E0.
Address
Death Certificate Filed District Number Register N •, •er
City, Town or Village Glens Falls 5601 1 \ 11
❑Burial Date Cemetery or Crematory
February 21,2017 Pine View Crematory
El Entorrbment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
,, Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1,. Remains are Shipped, If Other than Above
1; Address
ms'.
Permission is hereby granted to dispose of the human emains d scribed a ove as indicted.
Date Issued - Registrar of Vital Statistics L ,ir`� 4-
District (sig Number o X_��
"mi Place r
,,*,.„
l
I certify that the remains of the decedent identified above were disposed of in accot 7-/ ance with this permit on:
W Date of Disposition °z/ttji7 Place of Disposition ,n;u,,.,,. 6finatc.^.4,.,
2 (address)
W
CO
tY (section) f (lot number) ` (grave number)
pp Name of Sexton or Person in Charge of remises I ittls i" Sbnnlit
Z (pse print)
w Signature �� Title in IMPQ
(over)
DOH-1555 (02/2004)