Roman, Mark tt
NEW YORK STATE DEPARTMENT OF HEALTH e wir 1 J 15'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mark Edward Roman Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 14, 2016 59 War or Dates
I- Place of Death Hospital, Institution or
WCity, Town or Village Hudson Falls Street Address 33 King Aveunue
C; Manner of Death X❑Natural Cause 0 Accident Homicide Suicide ❑ Undetermined Pending
Circumstances Investigation
i Medical Certifier Name Title
PI Michael Sikirica MD,
Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village ` t)1.& v S
0 Burial Date Cemetery or Crematory
October 17, 2016 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
• and/or Address
p Hold
Date Point of
❑Transportation Shipment
(/) by Common Destination
C) Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I.
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
CC
LW
IL
• Permission is hereby granted to dispose of the human remains escribed above as indicated.
• Date Issued 10-1'1-j,t;l4 Registrar of Vital Statistics ,_,_ _.:o,,r LsOQADL
(signature)
District Number 5-1 a , Place r-
HE'
I certify that the remains of the decedent identified above were disp sed of in accordance with this permit on:
WP! Date of Disposition 10/17/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
WCO
(section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Pre ises 1 ) r'1r' Sl"Lq
z
et lease print)
W. Signature _ Title Gr V'���
(over)
DOH-1555 (02/2004)