Guy, Roger 0 16
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger Guy Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 5, 2014 60 War or Dates
t... Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause n Accident l l Homicide ri Suicide n Undetermined Pending
W Circumstances Investigation
twit Medical Certifier Name Title
CI Marvin Davidowitz MD
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 /
❑Burial Date Cemetery or Crematory
❑Entombment January 8, 2014 Pine View Crematorium
Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ i l Removal and/or Held
and/or Address
Nt' Hold
0 Date Point of
Ni l Transportation Shipment
p by Common Destination
Carrier
i l Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
tY
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued R- l '' I [ td Registrar of Vital Statistics LIJC -
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
gad C
� Date of Disposition � /5(ly Place of Disposition ,,�
111
(address)
Z0 (section) (tot num (grave number)
Name of Sexton or Person in Charge of Premises �,,,, ri-
W
(please print)
Signature Title Cir �fL
(over)
DOH-1555(02/2004)