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Gibbs, Roger Harry
T 1371 i NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Roger Harry Gibbs Male Date of Death Age If Veteran of U.S.Armed Forces, 12/30/2020 77 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Chester Town Warren Street Address 25 LaFlure Heights,Chester Town Warren,New York 12817 O Manner of Death © Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending W v Circumstances Investigation W Medical Certifier Name Title O Paul Bachman MD Address 9 Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Chestertown 5652 16 ❑Burial Date Cemetery,Crematory or Facility Name 12/31/2020 Plne View Crematorium ❑Entombment Address X❑Cremation Queensbury Hamlet,New York ❑Donation O Removal Date Place Removed and/or and/or Held N Hold Address 0 a 1-1 Date Point of U) ❑Transportation Shipment p by Common Carrier Destination Date Cemetery Address ❑Disinterment ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/31/2020 Registrar of Vital Statistics Mindy Conway(E(ectronicaCCy Signed) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition /—a—Ze7Z J Place of Disposition P:ae o 1,e,,,, C,„4#, 2 (addres W N CC (section) (lot number) (grave number) S Name of Sexton or Person in Ch a of Premis t?, �u tJ E l�)aer4 /please print/ W Signature /' � Title D eta,. t DOH-1555(07/18)p t of 2 i „7 ./ #asuaaq JO*tax s1opalm IEraund Fia[JO t ii uad"ieunq uo paureu auuoq Tu.zaun .mil unuasa.zdau haiatuaD main auk' r • r i OZ ;' - uo pazanupp , f: Jo suTuza.J ucuznH Tdpoag t r a (aZ)StIti 'aas nnul unIuaH atiand .