Rawlins, Cathy NEW YORK STAGE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cathy Ann Moses Rawlins Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 12, 2011 31 War or Dates
1.,. Place of Death Hospital, Institution or
,Z City, Town or Village Glens Falls i Street Address Glens Falls Hospital
0 -Manner of Death X Natural Cause I I Accident 1 Homicide Suicide - Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
G Rochid Daoui MD
Address
1 West Medical Suite 305 Saratoga Springs,NY 12866
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 17
l Burial Date Cemetery or Crematory
❑Entombment January 14, 2011 j Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12801
Date Place Removed
Z Removal and/or Held
0 and/or Address
E Hold
co
0 Date Point of
Ni I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
1
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01464
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
--2 Address
W. ._..
O.
Permission is hereb granted to dispose of the huma emains •escribed a•ove as indict ted.
Date Issued Registrar of Vital Statistics / i ' 4. a
' (signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition / J/4l/2o!/ Place of Disposition iqrLe. /fug" a ii,w.ti
(addr )
W
co 1(4`-//li4 �'
Qre (section) (lot number) (grave number)
Name of Sexton or Perso 'n Charge of Premises ,'ol/a,ec 4 .
z - (please print)
W
Signature Title may,6L&tL.
(over)
DOH-1555(02/2004)