Dearborn, Roger W NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roger W.Dearborn Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/08/2021 58 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
pManner of Death Natural Cause El Accident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
U Circumstances Investigation
Q Medical Certifier Name Title
Numan Rashid MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 507
Burial Date Cemetery,Crematory or Facility Name
09/10/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
❑
U) Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
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
Remains are Shipped,If Other than Above
2 Address
1=
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/10/2021 Registrar of Vital Statistics John Paul Franck(Electronically Signed)
(signature)
District Number 4501 Place Saratoga Springs, 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 9110174 Place of Disposition el701A. ,M„ lct'�
t1J (address)
W
tl)
(section) I (lot number/ (grave number)
GName of Sexton or Person in Charge of Pr ises ! n� ^Atfi
(pleake print)
W Signature /1 Title (1
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#