Roberts, Stephen f s 1 It c%.J
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
Stephen T. Roberts Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 25,2011 62 War or Dates
i_ Place of Death Hospital, Institution or
Z City, Town or Village Bolton Landing ; Street Address 409 Potter Hill Road
w Manner of Death Undetermined Pending
W Natural Cause Accident � �Homicide �X�Suicide
Circumstances Investigation
w Medical Certifier Name Title
0 Gary Scidmore _
Address
6930 State Rt.8,Brant Lake,NY 12815
Death Certificate Filed I District Number 1 Register Number 7
City, Town or Village Bolton 1
5650
❑Burial Date 1 Cemetery or Crematory
November 28,2011 j Pine View Crematory
❑Entombment Address
Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date ( Point of
NTransportation _ I Shipment
p by Common Destination
Carrier
Disinterment Date 1 Cemetery Address
Reinterment Date [Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
E Address
r4
w_ '
a
Permission is hereby granted to dispose of the si huma ins described above as indicated.
Date Issued 11'a g-2 o I I Registrar of Vital Statistics CktikeLeo (signature)
(si ,
District Number 5650 Place Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition I I-).9../oti Place of Disposition I,'n �c u L c u l Cr-e,r„ -,'j i 1
2 (address)
w
U)
C4 (section) clot number) (grave number)
ZName of Sexton or Person in Char of Premises ( t'pet o'hy Qd'vh t
w ----- - (please print)
Signature Title Cr-2,�,�1�rl 45S.
(over)
DOH-1555 (02/2004)