Morgan, Roger rine view tAeiliawiy
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roger K. Morgan Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2013 50 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Gansevoort Street Address 121 Forest Drive
• Manner of Death 0 Natural Cause Ell Accident Homicide El Suicide Undetermined Pending
Circumstances Investigation
W▪ Medical Certifier Name Title
0
John P. Stoutenburg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village
❑Burial Date 0s1221 2013 Cemetery or Crematory
Pine View Crematory
❑Entombment Address
®Cremation uuaker Road Queensbury,NY 12804
Removal Date Place Removed
z and/or Held Pine View Crematory
• and/or Address
E Hold Quaker Road Queensbury,NY 12804
Date Point of
0. Transportation Shipment
0 by Common Destination
E Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
} . Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human r ains describ above as indicated.
Date Issued 05 i3 Registrar of Vital Statistics Qv.
(signature) UJ\3?
District Number L61.03 Place ` O W`‘` O� �v r p
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition c-23-1 3 Place of Disposition Quaker Road Queensbury,NY 12804 Pg/11rc.iA44 j 4,1
W (address)
(section)ce n- � /'rlot`,n� 1/'sumber) � (grave number)
a ((1/11j"�/
0Name of Sexton Pers n i a of Premises `�
W /94 j C��(P 1 print)
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Signature Title
(over)
DOH-1555(02/2004)