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Farr, Roger K NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records14 Name First Mi a Last Sex Roger K. Farr _ Male Date of Death Age If Veteran of U.S.Armed Forces, 02/07/2021 89 Years War or Dates E.,, Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital Ici ll Manner of Death Undetermined Pending © Natural Cause ❑Accident ❑Homicide Suicide W Circumstances Investigation W Medical Certifier Name Title CI Mathew Varughese DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 85 ElBurial Date Cemetery,Crematory or Facility Name 02/08/2021 Pine View Crematory ElEntombment Address ElCremation Queensbury Town,New York ElDonation Z Removal Date Place Removed 0 Eland/or and/or Held H Hold Address N 0 d Date Point of Cl) LI Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Date Cemetery Address ❑Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/08/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) /signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 211 11,i Place of Disposition -7..1 /,,,/te— . 2 (address) W Cl)CC (section) /lot umber) (grave number) 0 �'�Name of Sexton or Person in Charge of Pr ises L- ��'i^�� z (please p(i r�t) W Title 11V(4.q.�Z Signature DOH-1555(018)p 1 of 2 1 Public Health Law Sec. 4145(2b) 0 14 519 Receipt I Human remains of - delivered on , 20 f Pine View Cemetery Representing the•funeral home named on-burial permit Official Funeral Directors Reg.or License# 4