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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Roger C Dayton Male
Date of Death Age If Veteran of US.Armed Forces,
10/30/2022 82 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Saratoga Hospital
IJJ
p Manner of Death ❑X Natural Cause EilAccident Homicide ESuicide ❑Undetermined ri Pending
W Circumstances Investigation
WMedical Certifier Name Title
CI Dean Reali DO
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 631
ElBurial Date Cemetery,Crematory or Facility Name
11/01/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o Removal Date Place Removed
and/or and/or Held
~ Hold Address
CO
0
o- Date Point of
CO LJTransportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
_► Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/31/2022 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition f1-/-20 Z Z Place of Disposition ,J P (f,`.e„ ) e 1 _ -L, 1,-4
2 (address)
W
NCC (section) (lot nu ber) (grave number)
gName of Sexton or Person in Cha of Premise 1-A'f n',A1 b l [T6s C
z ' / �l �(pllease print)
tL Signature 5,.yy Ai, Title 0 el 7�1
DOH-1555(07/18)pi.of 2
. :16 1
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#