Roberts, Charles F 01) . # IIS
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permii'1
Bureau of Vital Records
Name First Middle Last Sex
Charles F.Roberts Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2022 81 Years War or Dates 1958-1966
H Place of Death Hospital,Institution or
Z City,Town or Village Saratoga SONSStreet Address Wesley Health Care Center Inc
Manner of Death El Natural Cause ❑Accident Homicide ❑Suicide Undetermined ❑Pending
W
V Circumstances Investigation
la Medical Certifier Name Title
Rick Teetz MD
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed city of Saratoga District Number Register Number
Cit E,Town or Village 4501 202
Burial Date Cemetery,Crematory or Facility Name
04/02/2022 Pine View Crematory
Entombment Address
ECrenation Queersbury Town,New York
Donation
0❑Removal Date Place Removed
p and/or and/or Held
— Hold Address
0
O. Date Point of
(A❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
DReinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Otherthan Above
s Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04101/2022 Registrar of Vital Statistics DiZsm Moran('Eschtmic4/ly4rsa4)
(signature)
District Number 4501 Place city of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y Z_Z6ZL Place of Disposition 'rJe L "-ems.) Cr4ii4 -o P�-C
a (add ess/
W
CC N (section) (lot number) (graw number)
8 Name of Sexton or Person in Ch e of Pre es "Wee b t/,� n '+l
z r (ease print).
W Signature Title accr44
DOH-1555(07/18)p t of 2
•
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
•le View Cemetery Representing the funeral home named on burial permit
Funeral Directors Reg.or License# •