Sumner Jr, Roland NEW YORK STATE DEPARTMENT OF HEALTH 1 'g
Vital Records Section Burial - Tr s i e rm it
€« Name First Middle Last Sex
Roland Victor Sumner Jr. Male
= Date of Death Age If Veteran of U.S. Armed Forces,
IN January 30, 2014 91 War or Dates World War II
f Place of Death Hospital, Institution or
i City, Town or Village Street Address
Manner of Death Lurri Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
,11
Circumstances Investigation
W Medical Certifier Name Title
.141 Gerald F Abess MD,
Ilia
Address
3 Irongate Ctr. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
li-Qt City, Town or Village
❑Burial Date / — I , /Li Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
V Date Place Removed
2 ri❑ Removal and/or Held
Hold Address '
n Date Point of
a ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
,.' Permit Issued to Registration Number
€ Name of Funeral Home Carleton Funeral Home, Inc. 00281
g 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
Remains are Shipped, If Other than Above
a Address
if
W'
t- erm on ere granted Permission isted to dispose of the human r ins described a ove as 'ndicated.
Date Issued / I Registrar of Vital Statistics l l
_ (signature)
District Number 5'755 Place i pw� Fert L �r1k Eo tX ,_
' I certify that the remains of the decedent identified above_ (V were disposed of in accordance with this permit on:
Date of Disposition Q/3/wq Place of Disposition Quaker Road Queensbury,NY 12804
l (address)
Ui
(section) de (lot numbrr (grave number)
ta Name of Sexton or Per on in C arge of Premises / Arks "`%'��
z; (please print)
U.i,
,,. , Signature Title GINATT(42.
(over)
DOH-1555 (02/2004)