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Sluus, Roger NEW YORK STATE DEPARTMENT OF HEALTH 7/ b Vital Records Section Burial - Transit Permit Name First Middle Last Sex Roger Af 1c,r, Sluus Female Date of Death Age If Veteran of U.S. Armed Forces, April 20, 2016 68 War or Dates Vietnam Place of Death Hospital, Institution or W City, Town or Village Hudson Falls Street Address 40 River Street CI Manner of Death Undetermined Pending ]Natural Cause 0 Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title in Miriam Roth, M.D Dr. Address 113 New Holland Ave Albany, NY 12207 Death Certificate Filed District Number Register Number City, Town or Village 5—id-6 I `/ ❑Burial Date Cemetery or Crematory April 22, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed zriRemoval and/or Held and/or Address H Hold 03 Date Point of aEl Transportation Shipment I)' by Common Destination 6 Carrier Disinterment Date Cemetery Address 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 I— Remains are Shipped, If Other than Above • Address al .tt..' Permission is hereby granted to dispose of the human rema'ns described above as indicated. Date Issued Y /d1 r'4 Registrar of Vital Statistics ��A a . / (signature) District Number t /o Soh 1' ��-� Place (/, Hake, c� Mti TG / S I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: uj• Date of Disposition 04/22/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) [JhCa Ce (section) /"(lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises gnlhq'L S—t"^09— z Lit (plbase print) LU Signature A'`'`'�`- Title rainitsita- (over) DOH-1555 (02/2004)