Mass, Roslyn it
NEW YORK STATE DEPARTMENT OF HEALTH BurialTran Sit Permit
Vital Records Section
a.x: Name First Middle Last ' Sex
f. Roslyn Maas Female
Data of Death Age If Veteran of U.S. Armed Forces,
12 / 20 / 2017 92 War or Dates N/A
Place of Death Hospital, Institution or
"�: City,Town or Village Albany Street Address Daughters of Sarah Nursing gong r�. Manner of-death®Natural Cause ❑Accident Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances investigation
:0' Medical Certifier Name , / Title , , c�
h u/42.-iv, 4kbc.r, /rl.l.i
,,, Address
Aci' "'" (ct S. /4•14t--.,4^$0 r-j V Di 41/), Ali I .p-c>71/
..44,
< Death Certificate Filed District Number Register Number
City,'town or Vi►iage Albany .2g-i eo , ,
fit,®Budal Date 12 / 21/ 2017 Cemetery or Crematory
�Eritombm�erst Pine View Crematory ,
ry t -
:, Address W—
' , zuCremation Queensbury,
"'' Date { Place Removed
`. 0 Removal { and/or Held
and/or Address
•.. Hold
Date Point of
"`,[]Transportation Shipment
F� by Common Destination
Carrier
Disinterment Cemetery Address
"',Q Reinterment a- e Cemetery Address
11 Permit Issued to
Y,« Registration Number
fli Name of Funeral Home Compassionate Funeral Care 00364
fi Address
a``; 402 Maple Ave., Saratoga s,. P 9 sF WY 12866
N Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
Permission is hereby granted to dispose of the human remains d d above as indicated.
44
tt x Date Issued 42/o i 7 Registrar of Vital Statistics 7—.—.
>f ( attire)
0 District Number 4,0 i Place
Albany , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit an;
_"` Date of Disposition 726//7 Place of Disposition 7,ngv 7e,(4) l2.v,,,u.•45,4yr-rf (address) J
1, (section) (tot» mb[ (grave number)
r« Name of Sexto n in Charge of Premises 04 r'1L t.rrz 4---(e
(pleaseprint)
•::;; Signature ( Title L-l'z4 ,44/--
(over)
DOH-1555 (02/2004) \