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Rogers, Jr. Raymond NEW YORK STATE DEPARTMENT OF HEALTH Z Vital Records Section E • ,, Burial - Transit Permit Name First Middle Last Sex Raymond Clifford Rogers Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, 04/30/9019 75 years War or Dates 1 c n - 1962 1 Place of Death Hospital, Institution or 5 City, To i Street Address C XX Glens Falls Glens Falls Hospital Manner of Death©Natural Cause El Accident ❑Homicide ❑Suicide r-i❑Undetermined ri❑Pending LU Circumstances Investigation la Medical Certifier Name Title Pi Michael Adams M. D. Address 1448 Route 9, South Glens Falls, NY 12803 Death Certificate Filed District Number Register Number City, Towihpf*'iHJ X (=,IPns Falls 5A01 187 <s El Burial Date Cemetery or Crematory ❑Entombment 05/04/2019 Pine View Crematorium Address • IENfemation ' Queensbury, NY 12804 Date Place Removed . Z Removal and/or Held Q❑and/or i Address to Hold O Date Point of itl Transportation Shipment O by Common Destination mi Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address iiigi Permit Issued to Registration Number • Name of Funeral Home Edward L. Kelly Funeral Home 00519 Miiii Address Schroon Lake, N Y 12870 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above '„ Address IX Ilii P` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/30/2012 Registrar of Vital Statistics V.) C.A (A:) (signature) District Number 5601 Place Glens Falls /` v I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: III Date of Disposition S-- j-it _ Place of Disposition .Q,m°V.„ Cr y (address) U ta- IC (section) A (lot number - (grave number) L A Name of Sexton or erson in Ch ge of Premises ri ti,✓ l wy f Z ` � (please print) 10 Signature �� Title .C/101PrWL (over) DOH-1555 (02/2004)