Rogge, Carol NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
;iipii- Name First Middle Last Sex
Q�\ Tre con Rocve i--
Date of Death Age If Veteran of U.S.Armed Forces,
€':''s C2`1 ci 1 2.0\'-\ 1 \ War or Dates N I A-
t- Place • D eath Hospital, Institution or r
1Z City, own .r Village bur Street Address C qYl -(l :J e
Manner of Death KNatural Cause 0 Aciderit El Homicide 0 Suicide ri Undetermined 0 Pending
Circumstances Investigation
tu Medical Certifier Name Title
1.4 Cr;C � \\e
� ar \
F< Address
\OO -Pet e'l, S*-'u-' Gt j-s Pcx WS j N 1 1 a -CAI
Death Certificate Filed D t Number Register Number
City, Town or Village G 1 x S Ea\\S o c--) a i
2 Burial Date Cemetery or Crematory
oa, o'-4C } 2.U\A- Pi r\e_ \ c C°' - 0 ,-Y
Z:iE[Entombment- Address
<' ['Cremation atua V,ese cj c C Q-v\SbU(q ( N 1 12?OL'
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
D Transportation Shipment
1. by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i:l'iiii El. Permit Issued to Registration Number_
Name of Funeral Home Gy nal c maker V 0j {'t rr - 01 1 3 Q
>< Address
!1 La oyQ4-#e- S4 , aL. eensb,,ry , NJe yore 12'Si 0LA
'- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
. Permission is hereby granted to dispose of the human ains desc bed above as cated.
':« Date Issued a( I;ci( Registrar of Vital StatisticsG I }��
(signature)
District Number (Q c`7 Place / 0 L,,___Tim dr (-,- ,d,..s.2_12.4_,I.,
i 1 certify that the remains of the decedent identified above were disposed of in acc rdance with this permit on:
2/24/201 Pine View Cemetery
144 Date of Disposition `'lace of Disposition
I (address)
W. Horicon 9 E 1
kr (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises Connie L. Goedert
(please print)
iii
iiiiiiiSignature
Avoic i.'Ye c Title Superintendent
(over)
DOH-1555 (02/2004)