Rockefeller, Barbara ., —
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
`` Name First Middle Last Sex
f : Barbara D.Rockefeller Female
Date of Death Age If Veteran of U.S. Armed Forces,
t 01/03/2018 94 Years War or Dates
:' Place of Death
Hospital, Institution or
City, Town or Village Ballston Spa Village Street Address Saratoga Center for Rehab and Skilled Nursing
Manner of Death Natural Cause Accident Homicide Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
0 Vina Patel MD
Address
149 Ballston Ave,Ballston Spa Village,New York 12020
Death Certificate Filed District Number Register Number
City, Town or Village Ballston Spa Village 4520 2
i`v®Burial Date Cemetery or Crematory
01/05/2018 Pine View Cemetery
0 Entombment Address
❑Cremation Queensbury Town, New York
Date Place Removed
1 El Removal and/or Held
and/or
Address
Hold
Date Point of
❑Transportationvrit Shipment
by Common Destination
voi Carrier
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
NE
Address 1, Permission is herebygranted to dispose of the human remains described above as indicated.
p
F. Date Issued 01/04/2018 Registrar of Vital Statistics Teri Lee OConnor(cE(ectronica((ySigned)
1 (signature)
District Number 4520 Place Ballston Spa Village, New York
U4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IT Date of Disposition / ,2.dd Place of Disposition if 1;1.044 44 41.U.Q44.51/ezzi,
ddress)
alleaa., 2
(se (lot number) (grave number)
Name of Sexton or Person in Charge of Premises l v/t, E t. (70 4-
l se print) r
Signature ]-�f Title o 4 0-4-Lc
(over)
DOH-1555 (02/2004)