Mattern, Rose N, W YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ti
Name First Middle Last Sex
Rose Marie Mattern Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/23/2012 83 years War or Dates
.14, Place of Death Hospital, Institution or
fi City, TowgtQsofiIXx Glens Fails Street Address Glens Falls Hospital
ci, Manner of Death❑Natural Cause El Accident D Homicide 0 Suicide �Undetermined �Pending
ta Circumstances Investigation
la Medical Certifier Name Title
0 Derek_Smith M D
Address
G F Hospital 100 Park St. Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number i
City, Towixnyilw1219 (X Glens Falls 5601 302
gll❑RiArial Date Cemetery or Crematory
[]Entombment 06/26/2012 Pine View Cemetery
Address
-r eremation
Qi]eensbiary, NY 12804
Date Place Removed
Z Removal and/or Held
❑and/or
i;;; Address
Li)
Hold
0 Date Point of
a El Transportation Shipment
`Gi by Common Destination . .
Carrier
Q Disinterment Date Cemetery Address
liiiiilil
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
i
ni Address
11 Lafayette Street Queensbury, N Y 12804
Iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
Permission is hereby granted to dispose of the human remains described above as indicated.
gliii Date Issued G6/25/20 i2 Registrar of-Vital Statistics o n e
(signature)
o. District Number 5601 Place Glens Fall J .17
HiN I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
til Date of Disposition 6/26/12 Place of Disposition Pine View Cemetery
(address)
tii
W. Mohican 74 D 2
cc (section) (lot number) (grave number)
ci Name of Sexton or Person in C r of Premises Michael Genier
(please print)
1 Signature Title Superintendent
(over)
DOH-1555 (02/2004)