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Rozakis, Teresa - 5 � NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Teresa M.Rozakis Female • = Date of Death Age If Veteran of U.S.Armed Forces, Atrfr 04/10/2018 88 Years War or Dates •k Place of Death Hospital, Institution or City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 �» Death Certificate Filed District Number Register Number City, Town or Village Queensbury 5657 51 lei Burial Date Cemetery or Crematory 04/16/2018 Pine View Cemetery If El Entombment Address ❑Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of El Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number , Name of Funeral Home Regan Denny Stafford Funeral Home 01443 rAlt Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address ..ate Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/13/2018 Registrar of Vital Statistics Caroline 9f Barber(Electronical(ySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 4 /6, /A Place of Disposition sie , u_k_e'zsexe jr u (address) Oh.IL'D et) .20- ,C 2 ( on) (lot number) (grave number) Name of S or Perso ' rge of mises 't4)/( (pl print). Signatur Tit (over) DOH-1555 (02/2004)