Perry, Roger G NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
Roger G Perry Male
........................:....... ....................: :.........................: ...........................
Date of Death Age If Veteran of U.S. Armed Forces,
2 1 8 68 War or Dates WW 2
./....9 ...9............:.... ...................... ......::... P..............................:.............:............ ,.: ............:: ...........................................
Place of Death Hospital, Institution or
Z: City,Town or Village Saranac Lake Street Address General Hospital
!OWl y, 9
( :::Cause of Death ......
...................
..............................................................................................................................................................................................................
CARDIAC A REST
€..:.........:................::::::..................::..........:::::::::.::::::.::::::::.:::.::::::.:::::::::::::::::..:_:::::::::.:...: :::::::::::::. .. ........................_.._........_.......................___._............._.........
C�-i Medical Certifier Name Title
pa David Johnson, M. D. , Saranac Lake , N. Y .
........_:::Address............................................................................................................................................................................................................
Saranac Lake, N. Y .
: .. ...... . ....... .._::........................................:::::Reg:.:'ster NumberDe:at'lde::::rt:ificate...Filed......................... ........ .................... ...... sNDitrict umber :,::::..................
City,Town or Village Town of Harrietstown 1663
Date Cemetery or Crematory
El Burial 2/21/89 Pine View Crematory
....... ..... .... _..._ ......... __.. _.__. . _....... ......
...........................................................................................................................................................................................................................................
®Cremation Address
Glens Falls, NY
-. _ . __ ._ _.. _.. .. _ ___ _............................................................................................................................................................................................................................................................................................
Za Date Place Removed
Q'; El Removal and/or Held
t-' and/or Hold ............................... ... ...... ........ . ..... .............................
Address ..........::.:.................:..:::....................................................................: :........
N'.
0::.�...........
..P........:.......... ...........,...:....
..::...................................:..:....:..... . .. ..
G.' Date Point of
,n' Transportation by
Shipment
CommonCarrier ..........................................................................................................................................................................................
Destination
...:....:..............................:.......................................:....... ........ ... ......... .................... ........... .......... ...
❑ Disinterment
Date Cemetery Address
................:.......:....................... >..:.. .. .... ....,............................................................................................
❑ Reinterment
Date Cemetery Address
:> Permit Issued to Registration Number
Name of Funeral Firm M B Clark, Inc . 00422
.................................................................
:....
Address
27 Saranac Ave . , Lake Placid, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
....................................................................................................................................................................................................................................................................................
Permission is hereby granted to dispose of the dead human r m ins es ?d above a Indicated.
Date Issued 2/21/89 Registrar of Vital Statistics
gnature)
District Number 1663 Place Town of Harrietstown, Saranac Lake, NY 12983
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F.
W; Date of Disposition '-93_ Place of Disposition /Z:14cc�/i kj ��� � ,9' T/f/'(jz11
(address)
W
W (section) (lot number) (grave number)
pName of Secton or Person 'n Charge of Premises 7�? 4/
(please print) i
Signature Zc Title y
DOH-1555(9/86)p 1 of 2(formerly VS-61)