Boor, Roger C) G7
40'
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
1.. Name First Middle Last Sex
Roger K Boor Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 29,2015 63 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury
1Street Address 83 East Sunnyside Rd.
Manner of Death Natural Cause Accident Homicide X Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica
r,.rr1 Address
* 50 Broad Street,Waterford,NY 12188
rrh: Deat rtifiate Filed District Number R gi ter Number
r.: g , ►� va n 1
:IA Cit , Town oWilla e
❑Buna Date Cemetery or Crematory
December 31, 2015 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Glens Falls, NY 12804
Date Place Removed
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Removal and/or Held
and/or Address
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O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I$;: Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
; ° Address
:" 53 Quaker Road, Queensbury,NY 12804
..::. Name of Funeral Firm Making Disposition or to Whom
I: . Remains are Shipped, If Other than Above
Address
; :; Permission is hereby granted to dispose of the human r mains described above s indicated.
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nti Date Issued � ) l I }tVRegistrar of Vital Statistics C� ` . __1u
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k:: District NumbeK) ( c fl Place i (5 ✓r o (1 L 1.
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I certify that the remains of the decedent identified above were disposed of in accorda with this permit on:
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W Date of Disposition ( 3/-/c Place of Disposition PThe L'.e, ) Cift.,,. Jory
2 (address)
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O (section) t /� (lot number) (grave number)
p• Name of Sexton or Perso in Charge of Premises -J�/:�.1 (�4 •rt a-vf+-e
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Signature 2✓ Title Gre_r✓Lwl'
(over)
DOH-1555(02/2004)