Wescott, roxanna NEW YORK STATE DEPAk1MENT OF HEALTH
Vitalf4cords Section Burial - Transit Permit
Name First Middle Last Sex
Roxanna M Wescott Female
: Date of Death Age If Veteran of U.S. Armed Forces,
5/15/14 98 War or Dates NO
1+: Place of Death Hospital, Institution or
Z p$1t Town oriX Street AddressIli Montgomery Nursing Genter
3 Manner of Death®Natural Cause Accident 0 Homicide 0 Suicide ElUndetermined 0 Pending
maCircumstances Investigation
tu Medical Certifier Name Title
Syed Moin MD
Address
67 East Min St . Washingtonville NY 10992
Death Certificate Filed District Number Register Number
City, Town or Village 5/16/14
®Burial Date Cemetery or Crematory
5/19/14 Pine View Cemetery
['Entombment Address
;: < ['Cremation 21 Quaker Rd Queensbury NY
Date Place Removed
❑• Removal and/or Held
lei_ and/or Address
M Hold
in
0 Date Point of
Q` Transportation Shipment
Ct by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
pii Permit Issued to Registration Number
Name of Funeral Home Quic,ley Bros FH Inc. 1395
Address
337 Hudson St. Cornwall-On-Hudson NY 12520
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
W
',:i: Permission is hereby granted to dispose of the human remai described above as indicated.
Date Issued 6--1 ro—/9 Registrar of Vital Statistics 3 PA G
:4th"
(signature)
District Number Place TO w i., 4/e./ .0*(4er
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
5/19/14 Pine View Cemetery
tti• Date of Disposition Place of Disposition
(address)
fit Sec. 22 Uncas 756 2
(11
CC (section) (lot number) (grave number)
Name of Se n or Person in Charge of Premises Connie L. Goedert _
(please print)
`�- Title Superintendent
04,:i::: Signature; -
(over)
DOH-1555 (02/2004)