Haff, Roderick NEW YORK STATE DEPARTMENT OF HEALTH it S4 0
Vital Records Section ti . . Burial - Transit Permit
Name First Middle Last Sex
Roderick C. Haff Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 12,2012 57 War or Dates n/a
• Place of Death Hospital, Institution or
, City, Town or Village Moreau Street Address 1659 State Route 9 lot 23
0 Manner of Death n Natural Cause n Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ts
WI Medical Certifier Name Title
Michael Sikirica,Coroner
Address
Waterford,NY
r: Death Certificate Filed District Number Register Number
City, Town or Village Town of Moreau,NY
❑Burial Date Cemetery or Crematory
❑Entombment October 15,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
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O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
• Permit Issued to Registration Number
: Name of Funeral Home Regan& Denny Funeral Home 01444
Address
:.:3 94 Saratoga Avenue, South Glens Falls, NY 12803
:: Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
S Address
5
.• Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued /1-/�- /d2• Registrar of Vital Statistics /i .f� .� , f�
(signature)
District Number �,‘Z` Place Town of Moreau,NY
▪ I certify that the remains of the decedent identified above were disposed'RAJ of in accordance� with this permit on:
W Date of Disposition loty`IIL Place of Disposition J (,�-trn-d(--drw
W (address)
Cl)
CC (section) lot number (grave number)
Q Name of Sexton or Person in Charge of emises 4h.,/1
Z delsi--
��11(Please print)
W SignatureTitle Gte ly►YVrot
(over)
DOH-1555(02/2004)