Werner, Rose NEW YOI'K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rose M. Werner Female
Date of Death Age If Veteran of U.S. Armed Forces,
2/3/2011 76 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death LijNatural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
1.11 Circumstances Investigation
W Medical Certifier Name Title
Sean Bain, MT)
Address
100 Park Street Glens Falls , NY
Death Certificate Filed Glens Falls District Number 5 601 Register Number
City, Town or Village
®Burial Date Cemetery or Crematory
02/08/2011 Pine View Cemetery
; 0 Entombment Address
{j' OCremation Quaker Rd 0ueensbury
Date Place Removed
a Removal and/or Held
and/or Address
t Hold
0 Date Point of
BS El Transportation Shipment
G by Common Destination
Carrier
; >Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan and Denny Funeral Home 01464
Address
0ueensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
ILIA
`: Permission is hereby granted to dispose of the human remains des ribed aboyp as i i d.
Date Issued Registrar of Vital Statistics /44j,A �
(signature)
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 2/8/11 Place of Disposition Pine View Cemetery
a (address)
tii Mohican 90 A /
CC (section) (lot number) (grave number)
cl Name of Sexton or Person in harge of Premises Michael Genier
Z. (please print)
41
SignatureQ 2ti Title Superintendent
(over)
DOH-1555 (02/2004)