Martindale, Roger NEW YORK STATE DEPARTMENT OF HEALTH s 3 Z
Vital Records Section Burial - Transit Permit
Name First RogerMiddle Last Sex
9 John Martindale Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/25/2011 49 years War or Dates N /A
Place of Death Hospital, Institution or
ZCity, ToviH(dlrXV eXX Poughkeepsie Street Address Vassar Bros. Medical Center
Manner of Death p,PVatural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ri❑Pending
III Circumstances Investigation
iii Medical Certifier Name Title
a Brenda Ayers M D
Address_
Ieade Place, Poughkeepsie, N Y 12601
Death Certificate Filed District Number Register Number
City, Tov &XJ (X Poughkeepsie 1302 328
❑Burial Date ' Cemetery or Crematory
04/28/2011 Pine View Crematorium
❑Entombment Address
Ei KCremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
to
Date Point of
f t#❑Transportation Shipment
a by Common Destination
iiim Carrier
Q Disinterment Date Cemetery Address
iik- Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00276
Address
68 Main Street, Hudson Falls, N Y
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
Address
tr
I
II
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/26/2011 Registrar of Vital Statistics 1 �3c- E'
(signature)
<> District Number 1302 Place City of Poughkeepsie
`'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition IA q I(1 Place of Disposition 4)1Vtty (.rt,,.cty r iv,`
2 (address)
CC (section) (lot nu r) (grave number)
nName of Sexton or P on in Char a of Premises r�� �� hKt
z (please print)
41 0Sif ignature Title (ii
(over)
DOH-1555 (02/2004)