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Roseberger, Judy NEW YORK STATE DEPARTMENT OF HEALTH s ''"j Vital Records Section Burial - rarlit Permit 1 Name First Middle Last Sex Judy B. Roseberger Female 1.0 Date of Death Age If Veteran of U.S. Armed Forces, "r November 4, 2016 60 War or Dates NA 'rf' Place of Death Hospitat,4nstitution or City, Town or Village Glens Falls, NY Street Address 26 Harrison Ave#2, Glens Falls,NY Manner of Death ❑Natural Cause n Accident n Homicide n Suicide Undetermined n Pending Circumstances Investigation Medical Certifier 1Name Title Michael Sikirica MD It� Address ,. New Scotland Ave.Albany,NY ,, Death Certificate Filed District Number _J�VIJ Register Number gJ ;r City, Town or Village Glens Falls, NY ❑Burial Date Cemetery or Crematory November 7, 2016 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road,Queensbury,NY 12804 Date Place Removed Z ❑Removal and/or Held and/or Address ! Hold CO 0 Date Point of N ❑Transportation Shipment a by Common Destination Carrier — Disinterment Date Cemetery Address n Reinterment Date Cemetery Address a Permit Issued to Registration Number t�v - Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 r, Address 407 Bay Road, Queensbury, NY 12804 fV r, Name of Funeral Firm Making Disposition or to Whom '"I ' Remains are Shipped, If Other than Above Address g Permission is hereby granted to dispose of the human remains described above as undicated. IA Date Issued 11 )'t I 16 Registrar of Vital Statistics N rrac ��,,; (signature) _' District Number 5 j 0 t Place ( am.,C s Fc� \ \S ,&1� f' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z tu Date of Disposition /f�(jI Place of Disposition .411/' Cr ciorry-r (address) W co Ce (section) ht// (lot number) (grave number) pName of Sexton or Person in Charge of Premises � i �t+Ari' Z (ple`ase print) W Signature a .. Title lWlhDk- (over) DOH-1555(02/2004)