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Rock,Janet Rae
A�vN EW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Janet Rae Rock I Female Date of Death Age If Veteran of U.S.Armed Forces, 03/06/2020 74 Years War or Dates II.— Place of Death Hospital,Institution or Z City,Town or Village Hartford Town Street Address 659 Halls Pond Road, Hartford Town, New York 12832 W Manner of Death Undetermined Pending W © Natural Cause ❑Accident Homicide Suicide Circumstances Investigation V W Medical Certifier Name Title John Stoutenburg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hartford 5759 6 Burial Date Cemetery,Crematory or Facility Name 03/10/2020 Pine View Crematory Entombment Address XJ Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held ~ Hold Address N O IL Date Point of 0 Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address jo Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/10/2020 Registrar of Vital Statistics Denise Petteys(Electronically Signed) (signature) District Number 5759 Place Hartford, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZW Date of Disposition 3 I Place of Disposition P4.� ul (address) W N (section) �number) (grave number) Name of Sexton or Person in Charge of Premises �' It z W Signature Title tnPF—m koiz- DOH-1555(07/18)p 1 of 2 • e a � Public Health Law Sec. 4145(2b) Q 1 3 A-0 Receipt Human remains of delivered on , 20 ;;Kne View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#