Dolan, Rose NEW YORK STAW...DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rose Dolan Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 9, 2014 84 War or Dates
1.}.... Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 28 Ledgeview Dr.
aManner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
Lit Circumstances Investigation
� Medical Certifier Name Title
0
Address
Death Certificate Filed Queensbury District Number Register Number
City, Town or Village S CQ, (
❑X Burial Date Cemetery or Crematory
February 13, 2014 Pineview Cemetery
❑Entombment Address
❑Cremation Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
Z
and/or Address
E Hold
a)
O Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home William J. Burke & Sons Funeral Home 01827
Address
628 North Broadway,Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1Z
1t1
b.
Permission is hereby granted to dispose of the human remains described abo/ e.as indicated.
C..r Date Issued 2/11/2014 Registrar of Vital Statistics le. Ck. v� ...„
(signature)
District Number—) Place Queensbury
,i?z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 2/1 3/1 4 Place of Disposition Pine View Cemetery
W
(address)
Vy Wah Ta Wah 710 Sec. 26 1
CC (section) (lot number) (grave number)
Op Name of Sexto or Person in Charge of Premises Connie L. Goedert
Z C C
(please print)
WSignature y 12.A.c�� �- l-0-4 Title Superintendent
(over)
DOH-1555 (02/2004)