Bolton, Roger E (I & 4t OS
NEW YORK STATE DEPARTMENT OF HEALTH } Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roger E.Bolton Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/04/2022 88 Years War or Dates Unknown
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
Ca Manner of Death El Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
G Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 412
ElBurial Date Cemetery,Crematory or Facility Name
08/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
U)❑Transportation Shipment
p by Common
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment
Date Cemetery Address
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
1— Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/09/2022 Registrar of Vital Statistics 9,feganWblin(ECectronica1TySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z � L
Z Date of Disposition n o l i Z Place of Disposition �,, e4-____
UJ
2 (address)
W
N (section) /� //ot number) (grave number)
S� G
Name of Sexton or Person in Charge of P es 0, e ` 11
Z (pie e print) y�
W Signature Title �� �� lV'C`
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#