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Rolleston, Jean 0 1777 i fb NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit " Name First Middle Last Sex Jean M Rolleston Female Date of Death Age If Veteran of U.S.Armed Forces, " 09/15/2017 84 Years War or Dates F Place of Death Hospital, Institution or r City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre Y Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending Circumstances Investigation 14 Medical Certifier Name Title Came Miron PA Address 152 Sherman Ave,Queensbury Town,New York 12801 "* Death Certificate Filed District Number Register Number R w` City,Town or Village Queensbury 5657 119 ❑Burial Date Cemetery or Crematory 09/18/2017 Pine View Crematory ❑Entombment Address '®Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held x and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Sel Carrier '.❑Disinterment Date Cemetery Address P. ❑Reinterment Date Cemetery Address Ak oi, Permit Issued to I Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address a 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above e Address . Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/18/2017 Registrar of Vital Statistics carofinesfBar6r Eaaraaica/TySigned- (signature) s: 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: Ti Date of Disposition_lion � $ (Place of Disposition � ,r ,,. or,�. 1, �r" (address) ,--i 44. (section) (/qx number) (grave number) Name of Sexton or Person in Charge of Premises AIL59114( se print) Tr Signature Title AEigin (over) DOH-1555 (02/2004)