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Hayes, Roger L .A3 1... 6.6 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Roger L.Hayes Male Date of Death Age If Veteran of U.S.Armed Forces, 04/20/2023 69 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital pManner of Death ❑ n ❑ ❑Undetermined Pending 111 Natural Cause Accident I I Homicide Suicide U Circumstances Investigation Medical Certifier Name Title CI Daniel Wilkinson MD Address 43 New Scotland Ave,Albany, New York 12208 Death Certificate Filed City Of Albany District Number Register Number City,Town or Village 0101 0958 Burial Date Cemetery,Crematory or Facility Name 04/22/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town, New York Donation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address 0 O. Date Point of (1)1Transportation p by Common Shipment Carrier Destination II Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/21/2023 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed) (signature) District Number 0101 Place City Of Albany I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: , / Z Date of Disposition G ZZ Z)Z3Place of Disposition Pi`,J e V 4.0 ermi4 c'4-/ W 2 (address/ W CC N (section) (1 t nu ber) (grave number) 0 Name of Sexton or Person in Char of Prem' s F� �l�•a'J Wad Z (please print) W Signature ! Title be-e.r DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of ' delivered on , 20 • r /fps Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg. or License#