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Haskell, Roland NEW YORK STATE DEPARTMENT OF HEALTH _ - 1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roland M. Haskell Male _ Date of Death Age If Veteran of U.S. Armed Forces, November 3,2017 71 War or Dates Vietnam . Place of Death Hospital, Institution or City, Town or Village Warrensburg Street Address 14 Grand AvenueV_ Manner of Death Undetermined Pending , X Natural Cause Accident Homicide Suicide Circumstances Investigation , Medical Certifier Name Title `B' Schwerman Address HHHN,Schroon Lake,NY 12870 Death Certificate Filed District Number Register Number City, Town or Village Warrensburg 5660 ❑Burial Date Cemetery or Crematory November 6,2017 Pine View Crematory 0 Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address H Hold N 0 1 Date Point of O. 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 I Remains are Shipped, If Other than Above Address , Permission is he eb granted to dispose of the human remains d scribedabove as indicated. Date Issued ©( Registrar of Vital St _stic IPiG/✓ (signature) District Number 5660 Place Warrensburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z w Date of Disposition 8 / 1 i n Place of Disposition fi'mV.� 7(Jt►- .- (address) W Cl) CC (section) J (lot number) C (grave number) pName of Sexton or Person in Charge of Pre .ses /dry J PA id Z (pi ase print) W Signature Title (0611112. (over) DOH-1555 (02/2004)