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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia Roberts Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/05/2022 81 Years War or Dates
1— Place of Death Hospital,Institution or
Z City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death ❑X Natural Cause Accident El HomicideSuicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Brandii Baker NP
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed Town Of Argyle District Number Register Number
City,Town or Village 5750 58
EIBurial Date Cemetery,Crematory or Facility Name
11/09/2022 Pine View crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
- and/or and/or Held
F- Hold Address
N
O
IL Date Point of
UCTransportation Shipment
a by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
- Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
aAddress
CC
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n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued .11/09/2022 Registrar of Vital Statistics Sheltey ftMckernon(E(ectronicalTy Signed)
(signature)
District Number 5750 Place Town Of Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 111I L t-it Place of Disposition '`-'�—
W 6 /address)
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Cl)CC (sedion) ( number) (grave number)
8 Name of Sexton or Person in Charge o ises
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Z (please prr tl �,✓-�
w Signature Title ! ►►.ll
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b).
Receipt
Human remains of delivered on , 20
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#