Rosebrook, Gregory NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gregory A. Rosebrook Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 4,2016 64 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Troy Street Address 819 3rd Ave.
} Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
u Medical Certifier Name Title
G; Stephen Kineke MD
Address
1783 Route 9,Clifton Park,NY 12065
Death Certificate Filed District Number i01.
Register Number
City, Town or Village O� 4 3s-
❑x Burial Date Cemetery or Crematory
El
Entombment September 10,2016 Pineview Cemetery
Address
❑Cremation 53 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
cn
0 Date Point of
co Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Catricala Funeral Home Inc. 00301
Address
1597 Route 9, Clifton Park,NY 12065-4302
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
$ Address
W
C :
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued CI I(Q tip Registrar of Vital Statistics
(signature)
District Number 102,, Place City of Troy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
� Date of Disposition 9/10/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
(address)
co w New Hudson 3 13 6
(section) (lot number) (grave number)
pName of Sex on or Person in Charge of Premise Connie L. Goe
`Z (please print)
Signature Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)