King, Rosaline w
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
: f Name First Middle Last Sex
::1
e:: Rosaline M. King Female
Date of Death Age If Veteran of U.S. Armed Forces,
rr December 16, 2015 84 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I lAccident I 1Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Susanne Rayeski Dr.
:Kf: Address
: 100 Park Street,Glens Falls,NY 12801
::' .
rf Death Certificate Filed District Number Register Numb �
... •City, Town or Village Glens Falls 5601 ((
0 Burial Date Cemetery or Crematory
❑Entombment December 21, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
OF Date Point of
Ni !Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:::: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r;r Address
:::f 407 Bay Road, Queensbury, NY 12804
; f Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,i§: Address
Permission is herebygranted to dispose of the human remains described above as indicated.
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:.•::: Date Issued )2I/Sibs Registrar of Vital Statistics w c W
(signature)
;r r District Number 5601 Place Glens Falls, N"(
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ili Date of Disposition/, Vat j5'Place of Disposition �� ) .2/ d �i�=- a�a l bit
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.IA e A /35 A. /
o (section) /�(llot number) (grave number)
p Name of Sext n or Person in Charge of Premises CD/VitJi•6 L. UDE,062-T"
Z (please rint)
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Signatur _ ltC ce k-•j)- re Title 0J�/ -2�- -2 x
(over)
DOH-1555(02/2004)