Crofut, Roberta Denise V
11(1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
Roberta Denise Crofut Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/25/2022 65 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 20 White Birch Estates, Moreau Town, New York 12828
WManner of Death n Natural Cause []Accident n Homicide []Suicide []Undetermined ❑Pending
I !Circumstances Investigation
W Medical Certifier Name Title
Q
Eugene Ladue Coroner
Address
31 Woodlawn Ave.,Saratoga Springs,New York 12866
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 27
[]Burial Date Cemetery,Crematory or Facility Name
05/31/2022 I Pine View Crematory
Address
Cremation Queensbury Town,New York
JDonation
on Removal Date Place Removed
and/or and/or Held
Hold Address
O
a Date Point of
(/) Transportation
CI Common Shipment
Carrier Destination
oDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/27/2022 Registrar of Vital Statistics Leeann 91(1c cabe(ECectronicatCy Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition 5131 In Place of Disposition
W
2 (address)
W
CO
C (section) (lotf number) (grave number)
Name of Sexton or Person in Char of Premises
Z / ease print)
W Signature Title
DOH-1555(07/18)p 1 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#