Loading...
Rose, Evelyn _St G NEW YORK STATE DEPARTMENT OF HEATH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Evelyn May Rose Female i. Date of Death Age If Veteran of U.S. Armed Forces, ':1,1 August 15,2016 94 War or Dates r ? Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Deathlui17-71Natural Cause El Accident Homicide 0 Suicide n Undetermined n Pending Circumstances Investigation Medical Certifier Name Title Dr.Byrne MD Address 102 Park Street,Glens Falls,New York 12801 Death Certificate Filed District Number 56;0( Register Numb4j�ro City, Town or Village Glens Falls (( [�� 0 Burial Date Cemetery or Crematory August 22, 2016 Pine View Crematorium D Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ ri❑Removal and/or Held and/or — Address E Hold Cl) Q Date Point of N ['Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom , yL Remains are Shipped, If Other than Above Address • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 3 f i s!23 14, Registrar of Vital Statistics t�}t.A),. rs \. LA, c4r (signature) District Number 5 Q) Place 7 ( S `\s / 0 u I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z p W Date of Disposition D 77m, Place of Disposition / r 12 V 1 Pu) Greentiorif W (address) co W (section) (yI t number) (grave number) QName of Sexton or Pe on in C rge of Premises S ti-tik.v• (a.enavi,2 Z (please print) W Signature Title C.re-Me.. i (over) DOH-1555(02/2004)