Slayback, Roger Jon ,L ` .7S2
NEW YORKSTATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roger Jon Slayback Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/21/2022 78 Years War or Dates
f., Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
W 0 Natural Cause Accident ❑Homicide Suicide
Circumstances Investigation
WMedical Certifier Name Title
0 David Cunningham MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 485
Burial Date Cemetery,Crematory or Facility Name
® 09/22/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
tlt) Transportation
ES Common Shipment
Carrier Destination
El
Disinterment
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
N Address
Q
W
CI. Permission is hereby granted to dispose of the human remains described above as indicated.
Date"Issued 09/22/2022 Registrar of Vital Statistics Megan Wolin(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:
W Date of Disposition 9 r'Z31ZZ Place of Disposition �n.alL o--�.
(address)
W
fp (section) / /lotnumber/ (grave number)
Q L � tIv �
O Name of Sexton or Person in Charge of re ises ��
Z 4ease print)
W Signature Title l eiF/roll-pit
DOH-1555(07/18)pi 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# "%'