Roth, Henry William .;. gib
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Henry William Roth Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/22/2021 91 Years War or Dates 1947-1948
Place of Death Hospital,Institution or
Z City,Town or Village Schroon Town Street Address 38 Fowler Avenue#206,Schroon Town,New York 12870
0 Manner of Death XI Natural Cause Accident DI HomicideSuicide Undetermined Pending
Circumstances Investigation
C Medical Certifier Name Title
Kellie Valentine Coroner
Address
PO Box 132,Elizabethtown Town,New York 12932
Death Certificate Filed District Number Register Number
City,Town or Village Schroon Lake 1563 7
Burial Date Cemetery,Crematory or Facility Name
09/24/2021 Pine ViewCrematorrrrrm
Entombment Address
0 Cremation Queensbury Hamlet,New York
ElDonation
Z ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
Cl) ❑Transportation Shipment
5 by Common
Carrier Destination
ElDisinterment Date Cemetery Address
ReintermeM 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
E.. Remains are Shipped,If Other than Above
2 Address
CC
IW
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/24/2021 Registrar of Vital Statistics glitricia Savant(ECectronicaQySigned)
(signature)
District Number 1563 Place Schroon Lake, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q(Z1ill Place of Disposition +tc lx... r‘,......_
W (address)
W
LC (section) f� (lot number) (grave number)
SName of Sexton or Person in Charge of Premises N �-- SA...4 it
Z (plea e print)
W Signature a Title 61Kr41 ('fl4‘.
DOH-1555(07/18)p 1 of 2
015178
Public Health Law Sec. 4145(2b)
Receipt
•-Sk 7_
Human remains of / - delivered on • ,
`-•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License