Murray Sr, Roger NEW YORK STATE DEPARTMENT OF HEALTH 1'1 '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger John Murray Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 11, 2015 73 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Street Address Glens Falls 060536
O Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
t3
W Medical Certifier Name Title
James North, M.D
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number Register N mber
City, Town or Village _56. / S /
❑Burial Date Cemetery or Crematory
September 14, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0; and/or Address
F.: Hold
Date Point of
❑Transportation Shipment
'` by Common Destination
O Carrier
Date Cemetery Address
El Disinterment
❑ Renterment 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
H Remains are Shipped, If Other than Above
2 Address
CC
a Permission is hereb granted to dispose of the human I-mains • -scribed above as indi ated.
Date Issued O / Registrar of Vital tatistics �i / /ANC:
/ (signature)
District Number Place Air '
I certify that the remains of the decedent identified above were disposed of in accord ce with this permit on:
W; Date of Disposition 09/14/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
,, (section) A (lot number) (grave number)
❑, Name of Sexton or Person in Charge of Premises ns� fie„,,, .
Z (please print)
W Signature !��"t- Title civihigoie
(over)
DOH-1555 (02/2004)