Tate Jr, Roger E 1
3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger Tate Jr. Male
iM Date of Death Age If Veteran of U.S. Armed Forces,
10 / 08 / 2016 52 War or Dates
} Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
tti0 Manner of Death®Natural Cause 0 Accident 0 Homicide Ei Suicide �Undetermined �Pending
its Circumstances Investigation
tu Medical Certifier Name Title
Q Paul Dittes MD
Address
454 Maple Ave Saratoga Springs, NY 12866
Death Certificate Filed District Number � , Register Number
City,Town or Village Saratoga Springs
Burial Date Cemetery or Crematory
10 / 11 / 2016 Pine View Crematory
CEntombment Address
EiCremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
a., and/or Address
tt Hold
0
Ct Date Point of
Q Transportation Shipment
ES. by Common Destination
Carrier
[l Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
'[> Address
402 Maple Ave. , Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
is
"`. Permission is hereby granted to dispose of the human remai rib aboA
as' dicated.
Date Issued !� 1 Registrar of Vital Statistics
I 12DIU • (signature)
District Number 450` Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lit Date of Disposition /ol)Z fa, Place of Disposition U1.1.0 Cfr Citx.^
a (address)
Ul
CC (section) (lot number)e. (grave number)
CI
Name of Sexton or Person in Charge of remises r�f>
lease print) •
Signature (�'� TitlenvEstutid
(over)
DOH-1555 (02/2004)