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Gornell, Rosa
1 //n NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rosa Gornell Female Date of Death Age If Veteran of U.S.Armed Forces, 04/26/2020 88 Years War or Dates 11-- Place of Death Hospital,Institution or Z City,Town or Village Freeport Village Street Address Meadowbrook Care Center, Inc pMannerof Death © Natural Cause Accident Homicide Suicide Undetermined ❑Pending W Circumstances Investigation (U W Medical Certifier Name Title 0 Aijaz Khan MD Address 320 W Merrick Rd,Freeport Village,New York 11520 Death Certificate Filed District Number Register Number City,Town or Village Freeport 2904 113 Burial Date Cemetery,Crematory or Facility Name 04/29/2020 Pine View Cemetery&Crematorium QEntombment Address Cremation Queensbury Hamlet,New York Donation OZRemoval Date Place Removed and/or and/or Held H N Hold Address O a Date Point of CO) Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address in Reinterment I Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home N F Walker Inc 01234 Address 2039 Merrick Avenue,Merrick Hamlet,New York 11566 Name of Funeral Firm Making Disposition orto Whom Remains are Shipped,If Other than Above 2 Address Ir W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/28/2020 Registrar of Vital Statistics McCind-a Gee(ECectronicaCCy Signer) (signature) District Number 2904 Place Freeport, New York I certify that the remains of the decedent identified above were dis ed of�inn accordance with this permit on: Z Date of Disposition *301'o Place of Disposition i'l he y(e,,� Z/ l Li 4 eexs 1 (address) W t N (section) (lot number) (grave number) j Name of Sexton or Person in Charge o Premises x (please print) W Signature Title DOH-1555(07/18)P 1 of 2 Public Health Law Sec. 4145(2b) 0 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#