Roberts, Margaret Meade t...-. .\
NEW YORK STATE DEPARTMENT OF HEALTH
./ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Margaret Meade Roberts Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/13/2022 86 Years War or Dates
I_ Place of Death Hospital,Institution or
WCity,Town or Village Gloversville Street Address Mountain Valley Hospice
p Manner of Death X Natural Cause Accident []Homicide Suicide Undetermined []Pending
IllCircumstances l 'Investigation
W Medical Certifier Name Title
0 Kevin Cope MD
Address
108 Steele Ave,Gloversville, New York 12078
Death Certificate Filed City Of Gloversville District Number Register Number
City,Town or Village 1701 271
EiBurial Date Cemetery,Crematory or Facility Name
10/17/2022 Pine View Crematorium
[]Entombment Address
MCremation Queensbury Town,New York
CDonation
O[]Removal Date Place Removed
and/or and/or Held
N Hold Address
N
0
EL Date Point of
N[]Transportation Shipment
Q by Common
Carrier Destination
ri
Disinterment
Date Cemetery Address
[]Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/17/2022 Registrar of Vital Statistics Devon(Davis(ECectronicaiCySigned)
(signature)
District Number 1701 Place City Of Gloversville
I certify that the remains of the decedent identified alcove were disposed of in accordance with this permit on:
' 1/ /
Z Date of Disposition 10111 117, Place of Disposition 'I .A V� I J�T
W (address)
W
O(section) I1I
(lot n rmbei/Sm.) (grave number)
Name or Person in arreises l�
Z ofSexton Charge r�f P (p�ase print)
pJ Signature _. Title Chit,'4 -01?
DOH-1555(o7/18)p 1 of 2
7
kk N(h\3 3 C
Public Health Law Sec. 4145(2b)
Receipt
1 •
1 Human remains of delivered on , 20
1
1
Pine View Cemetery Representing the funeral home named on burial,permit
Official Funeral Directors Reg.or License#