Rose, William NEW YORK STATE DEPARTMENT OF HEALTH ��
Vital Records Section Burial - Transit Permit
Name First Middle ' Lest Sex
William F. Rose Male
ti; Date of Death Age If Veteran of U.S.Armed Forces,
.t March 24,2017 74_ War or Dates Yes
Place of Death - Hospital, Institution or
•,„ City,Town or Village Albany Street Address Albany Medical Center Hospital
_. Manner of Death❑Natural Cause El Accident 0 Homicide n Suicide ❑Undetermined ❑Pending
"" Circumstances Investigation
a; Medical Certifier Name Title
ti
s Address
;Y
Death Certificate Filed District Number Register Number
4 City,Town or Village
``'0 Burial Date Cemetery or Crematory
March 27,2017 Pine View Crematory
•. ❑Entombment Address
'-:®Cremation 21 Quaker Rd.,Queeusbury,NY 12804
ztv
Date Place Removed
s 0 Removal and/or Held •
and/or Address
Hold
O. Date Point of
4/3❑Transportation Shipment
4 by Common Destination
Carrier
--x❑Disinterment
Date Cemetery Address
i.-
_. Date Cemetery Address
❑Reinterment
: ; Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
:If: Address
' 3809 Main Street,Warrensburg,NY 12885
';':: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
hr Permission Is ereby granted to dispose of the human remains descr'bed abo es Indicated.
, „ Date Issued �,. Registrar of Vital Statistics ... nik�!i2' f Y
111'�'' (s )
l•
.LJ District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ni Date of Disposition 3 J2$ )() Place of Disposition eUak... Eitoc k_.., •
r u (address)
Te (section) (ha number) , (grave numbed
fi Name of Sexton or Person in Charge of P mises /% r ,Sa,,4/}t
�/ tease print
_: Signature /,� Title ((L •l'?j1 4,
..
(over)
DOH-1555(02/2004)