Clothier, Roger 7/ /
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
A,,
Name First Middle Last Sex
Roger William Clothier Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 27, 2015 52 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death Natural Cause ❑ Accident I I Homicide ❑ Suicide ❑ Undetermined ❑ Pending
iii
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica , Dr.
Address
50 Broad Street Ste 1 Waterford, NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village
0 Burial Date Cemetery or Crematory
September 29, 2015 Pine View Crematory
r, �❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
(❑Transportation Shipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reby granted to dispose of the hum emai des Fib 11 s indicated.
Date Issued 92/h.s Registrar of Vital Statist. va
(signature)
District Number 17{5 Place �C9'.-41, '72
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/29/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot numbs (grave number)
gi Name of Sexton or Pers n in Charge of Premises Hnrt )(K 001
lease print)
111
Si 9 nature f /(4-- Title
(over)
DOH-1555 (02/2004)