Rowland, Diane goo/5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane Rowland Female
Date of Death Age If Veteran of IJ.S. Armed Forces,
01/05/2006 64 years War or Dates
Place of Death Hospital, Institution or
City, Town d(XXIXIc) XXXX City Of Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Fatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LU Circumstances Investigation
W Medical Certifier Name Title
John Stoutenburg M D
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Town a004)6c�6XXXX City Of Glens Falls 5601 8
0 Burial Date Cemetery or Crematory
❑ 01/09/2006 Pine View Crematorium
Fptombment Address
,Cremation Queensbury, NY 12804
Date Place Removed
t ri Removal and/or Held
and/or Address
F= Hold
CA
0 Date Point of
)0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
M!ElReinterment Date Cemetery Address
4i ElPermit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01194
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LU
CL
Permission is hereby granted to dispose of the human remains described bove as i icat .
Date Issued 01/06/2008 Registrar of Vital Statistics
(signature)
District Number 5�Q/ Place '/�� ��, /,>t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I ;r.,,c)f Place of Disposition ¢)/ LI C4,/fi G�r 10 /t,(4 o rZ.i,t.) �.
l / (address)
Ili
co
cc (section) (lot number) (grave number)
et
ci Name of Sexton or Person in Charge of emises al'Pr t2--'/. - ('�'H �'
2 (please print)
iii Signature Title ( Nl i 7-rCJ 1.7/
(over)
DOH-1555 (02/2004)