Rose, Harold ° k `J 2 L-1
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
i , Name First Middle Last Sex
Harold John Rose Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/30/2017 59 Years War or Dates 1977-1986
▪ Place of Death Hospital, Institution or
W City, •Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death El NaturalCause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
G Courtney Stewart NP
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 615
.- ❑Burial Date Cemetery or Crematory
ti 12/01/2017 Pine View Crematorium
}` ❑Entombment Address
;': ®Cremation Queensbury Town, New York
Date Place Removed
2❑Removal and/or Held
and/or Address
Hold
CO
0 Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
t Address
g-R 68 Main Stpo Box 67,Hudson Falls,New York 12839
'' Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
W
¢" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/01/2017 Registrar of Vital Statistics Vert)!Curtis fECectronicaaySigned
} (signature)
District Number 5601 Place Glens Falls, New York
t` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition /2-AY-1 7 Place of Disposition ?,)I.e-.,) j J 6✓y—,, b_kr
W (address)
eg (section) (lotf umber) (grave number)
2 Name of Sexton or Perso n C arge f Premises �) Q✓t L9 a-'4.1.4-f.•--c
(please print)
W Signature Title Ct�'L
(over)
DOH-1555(02/2004)