Rozell, Lina if'
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
N Name First Middle Last Sex
w Lina Lee Rozell Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/06/2017 75 Years War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitati
r Manner of Death 5 Natural Cause 0 Accident El Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Gwendolyn Morris-Dickinson PA
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 629
��❑BUrlal
Date Cemetery or Crematory
- 12/07/2017 Pine View Crematory
❑Entombment Address
• ®Cremation Queensbury Town, New York
01
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
• Transportation Shipment
1 by Common Destination
Carrier
w.- �]Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
et
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
R• emains are Shipped, If Other than Above
•R Address
'a
-=y Permission is hereby granted to dispose of the human remains described above as indicated.
it Date Issued 12/06/2017 Registrar of Vital Statistics Ko6ertsCurtis EactronwaaySigned
(signature)
District Number 5601 Place Glens Falls, New York
tp
.414 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I Z f s 1 fl Place of Disposition fpk",... to
3 (address)
(section) n (lot number) (. (grave number)
NI
N• ame of Sexton or Person in Charge of remises G 4r.4 .J i"'..`tti
Cil
(please print)
S• ignature a K Title �" EM�g-
,n i i
(over)
DOH-1555 (02/2004)