West, Ronald NEW YORK STATE DEPARTMENT OF HEALTH' '
Vital Records Section Burial - Transit Permit
to ,
Name First Middle Last Sex
Ronald V. West Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 22,2011 66 War or Dates 1962-65
Place of Death Hospital, Institution or
W City, Town or Village Saratoga Street Address Saratoga Hospital
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined —Pending
Circumstances Investigation
V
W' Medical Certifier Name Title
Rodney Ying MD
Address
59 Myrtle Street.,Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Numb r
City, Town or Village Saratoga Springs 4501 c
❑Burial Date Cemetery or Crematory
El Entombment 6/22/2011 Pineview Crematory
Address
0 Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or I Address
N Hold
co
0 Date Point of
cn Transportation I Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01136
Address
PO Box 277,Fort Ann,New York 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human rema' cr' ed awe indicat d.
Date Issued 6/22/2011 Registrar of Vital Statistics 1'
(signature)
District Number Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I. 173/l' Place of Disposition C_s^'^Ncfp
(address)
N
cc (section) a ,(lot
nmber) (grave number)
cp Name of Sexton or P son in Charge f Premises r,� �t
Z f (ple se print
Signature /"� L Title C1). ►w`
9 �I
+( (over)
DOH-1555 (02/2004)