Roche, Lenore NEW YORK STATE DEPARTMENT OF HEALTH it a
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lenore Roche Female
Date of Death Age If Veteran of U.S.Armed Forces,
. January 24, 2011 9 7 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Granville Street Address Indian River Rehabilitation and
0 Manner of Death Watural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Nam Titlee
W J2 ,,2 i1 "ye...S. /22 )
Q Address
/7 #11 0S4'n.
Death Certificate Filed stri mb Register ber
City,Town or Village Granville -ja.
❑Burial Date Cemetery or Crematory
January 26, 2011 Pineview Crematorium
❑Entombment Address
m [I Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
l' Hold
N Date Point of
0 ❑Transportation Shipment
O. by Common Destination
,A Carrier
+_� Date Cemetery Address
ow ❑Disinterment
U ❑Reinterment Date Cemetery Address
1
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IX
W Address
0.
Permission is her by granted to dispose of the human remat s described above as indicated.
Date Issued �/dJr// Registrar of Vital Statistics - </E; L �'``
(signature)
District Number 6-7 3' Place Granville,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 01/26/2011 Place of Disposition Pineview Crematorium
2 (address)
N
IX (section) lot numb (grave number)
4
ZName of Sexton or Pers n in Charge of P emises 4,,,,,ph, ..,fit,,4
lL (please print)
Signature Title t 1f/=w 1iTOR-
(over)
DOH-1555 (02/2004)