dickson, Roland NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section i Burial - Transit Permit
Name First Middle Last Sex
Roland Dickson Male
Date of Death Age If Veteran of U.S. Armed Forces,
0912f 2111�2014a h 82 years War or Dates
N Place o e Hospital, Institution or
W City, Torn.orV1J Street Address
.d Manner o ea{i Natural Cause Accident ❑Homicide ❑Suicide i d ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
Q
Ad§ecsD. Teetz M. D.
131 Lawrence Street, Saratoga Springs N Y
Death Certificate Filed District Number Register Number
City, Tob'fCCX Saratoga Springs 4t501 421
A❑Burial a tery or Crematory
El Entombment Address09/23/2014 Pine View Crematory
[ remation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
9 ❑and/or Address
H Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Care, Inc. 00364
Address
Name of0 2u M ale F Arve eSga rD as Sit ornn st oWYh 1om66
1 Remains are Shipped, If Other than Above
Address
i
i
Permission is hereby granted to dispose of the human rema_tns..ldescribed above as indicated.
n
Date Issued 09/23/2014 Registrar of Vital Statistics °..;-_ 1 a --4,i,x,,,A
(signature)
District Number Place
4501 Saratoga Springs
1 � r!'`b~I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
til Date of Disposition iirI Place of Disposition --Z IA) (r0r--
(address)
L
ta
CC (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises /n+77. St
z; (please print)
41 Signature ��f __• Title « 13it
(over)
DOH-1555 (02/2004)