Rosa, HelenaNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
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Burial - Transit Permit
Name First Middle Last Sex
Helena Rosa ------- _j Female
Date of Death 1Age If Veteran of U.S. Armed Forces,
9/30/2019 1 73 _ War or Dates
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_ _ _
Place of Death Hospital, Institution or
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City, Town or Village Granville Street Address 141 Aiken Rd.
pManner
of Death Q Natural Cause [:]Accident ❑ Homicide ❑ Suicide ❑Undetermined ❑Pending
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Circumstances Investigation
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Medical Certifier Name Title
Wesley Perry, Coroner__ -
Address
Washington County - Granville, New York
Death Certificate Filed District Number _ Register Number
ID
City, Town or Village Granville
❑ Burial
Date Cemetery or Crematory
October 4, 2019 Pine View Crematorium
❑ EntombmentAddress
_
® Cremation
51 Quaker Road, Queensbury, NY 12804
Date
Place Removed
ZZ
❑ Removal
and/or Held
----- ----- -- -----
-
and/or ---- ---- —
Address
Hold
Date Point of
IL
N
❑ Transportation Ship ment
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by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
---- ---- -- — - —
-----
❑ Renterment
------- -
Date
Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home -
01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-
Remains are Shipped, If Other than Above
Address
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- — - - -- --
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Permission is hereby` to dispose of the human remains descri ed above as indicated.
`granted
Date Issued E7 t) I�0( Registrar of Vital Statistics v4 )210,46
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(si nature)
District Number 5 j S6 Place Granville
o,�rdance with this permit on:
I certify that the remains of the decedent identified above were disposed of in acc`oe4..
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Z
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,� V Cc..Adr%u-
Date of Disposition to) �1 Place of Disposition ,..�
2
(address)
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W
lot number) (grave number)
O(section)
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Name of Sexton or Person in Charge of Pre ises 1 -'Q �' 2e
(ple a print)
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Signature Title 14AAMC
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 012581
Receipt
Human remains ofdelivered on ! , 20
Pine View Cemetery presenting/the funeral home named on burial permit
Official Funeral Directors Reg. or License # A > ' 2