Havens, Roy NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit
' Vital Records Section
Name First Middle Last Sex
Roy Alexander Havens Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/14/2018 89 Years War or Dates
Place of Death Hospital, Institution or
WCity, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
W Manner of Death®Natural Cause Accident Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
CI Carrie Miron PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
7 City, Town or Village Queensbury 5657 39
' 0 Burial Date Cemetery or Crematory
03/16/2018 Pine View Crematorium
❑Entombment Address
®Cremation Queensbury Town. New York
Date Place Removed
0 Removal and/or Held
F and/or Address
Hold
In
O Date Point of
nElTransportation Shipment
8 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Ir.- Remains are Shipped, If Other than Above
Address
re
Ll,i
Cl Permission is hereby granted to dispose of the human remains described above as indicated.
,, Date Issued 03/15/2018 Registrar of Vital Statistics Caroline X Z artier(E4ctron caffy Signed)
(signature)
z, District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed!of in accordance with this permit on:
Date of Disposition 3iii 116 Place of Disposition MV.� Lads)�—
v" (address)
Cn
1Z (section) (lot number) (grave number)
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Name of Sexton or Person in Charge of Premises �,�
► i3 (please print)
i Signature �1 •„4- Title [t"ifitkt
(over)
DOH-1555 (02/2004)