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Hall, Roy NEW YORK STATE DEPARTMENT QF*HEALTH 413 Vital Records Section Burial - Transit Permit I Name First Middle Last Sex Roy Albert Hall Male Date of Death Age If Veteran of U.S. Armed Forces, January 8, 2017 76 War or Dates �I Place of Death Hospital, Institution or City, Town or Village Hudson Falls Street Address 166 John Street Ci Manner of Death J Natural Cause � Accident Homicide Suicide Undetermined Pending Circumstances Investigation Ur Medical Certifier Name Title Paul R Filion, M.D. Dr. Address Three Iron Gate Center Glens Falls, NY 12801 .; Death Certificate Filed District Number Register Number City, Town or Village S 7 a- 4 / ❑Burial Date Cemetery or Crematory January 16, 2017 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held 0and/or Address ;[ Hold IA, Date Point of ur❑Transportation Shipment by Common fi Carrier tik Disinterment Date Cemetery Address rz Reinterment Date Cemetery Address Permit Issued to Registration Number { Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom IMY Remains are Shipped, If Other than Above Address Liti Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ///t/ /7 Registrar of Vital Statistics t t , ,., (signature) District Number 7 Place //; /l4 r ii 1 li. ...L fl_ v ,' it I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 01/16/2017 Place of Disposition Quaker Road Queensbury,NY 12804 ` (address) le (section) rlot number) (grave number) > Name of Sexton or Person in Charge of Premises L rill- Sitt z (ple se print) 'wi,III Signature s Title /Ilbei, (over) DOH-1555 (02/2004)