Roberts, Greyson NEW YORK STATE DEPARTMENT OF HEALTH. li `Z f
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Greyson A. Roberts Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/23/2013 0 years War or Dates
iii. Place of Death Hospital, Institution or
ii City, TowXX 'ilj XX Glens Falls Street Address Glens Falls Hospital
a Manner of Death❑Natural Cause TI Accident ❑Homicide ❑Suicide [:IUndetermined ❑Pending
USCircumstances Investigation
i Medical Certifier Name Title
ti
Lynette Biss Cnm
Address
90 South Street, Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TowN)j'iIXX Glens Falls 5601 2
gR❑Burial Date Cemetery or Crematory
Z❑Entombment 07/25/2013 Pine View Crematorium
Address
NC�yemation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
i= Hold
an
O Date Point of
t�30 Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address .
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander- Baker Funeral Home 00037
Address
3809 Main Street Warrensburg, N Y 12885
ID Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
CL
Permission is hereby granted to dispose of the human remains described aboie as indicated.
iiN Date Issued 07/25/2013 Registrar of Vital Statistics IA)G%,p.Z C.n..�./•+i
(signature)
District Number 5601 Place Glens Falls 0 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition 1- Z -L?) Place of Disposition FivitiOc{‘j
2 (address)
UI
CC (section) (lot number) (grave number)
• Name of Sexton or Perso in Charge of Premises r.it c 3,41
(pie se print)
• Signature 7 17 ._.- T Title LafIY)IS`tDQ.
(over)
DOH-1555 (02/2004)