Rogers, Herbert Jackson , I,UF\ 'giglif
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Herbert Jackson Rogers Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/07/2022 68 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 1106 Towpath Road, Kingsbury Town, New York 12839
1p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
a Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 20
Burial Date Cemetery,Crematory or Facility Name
10/12/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
go❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
CO
0
O. Date Point of
Cl)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
M Address
EC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrar of Vital Statistics Cynthia Bardin(ECectronicaCCySigned)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W //____
Date of Disposition 1'n 114 12L Place of Disposition ,lr�
t /
2 (address)
W
Q (section) (lot number (grave number)
!g Name of Sexton or Person in Charge of Pre 'ses " ` L r','�,it
z / (please print)
W Signature Title �2Fm►� �
DOH-1555(07/18)p t 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#