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Rozell, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH 1 Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Charlotte Rozell Female Date of Death Age If Veteran of U.S.Armed Forces, 10/14/2020 88 Years War or Dates F— Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc 0 Manner of Death © Natural Cause 0 Accident ❑Homicide 0 Suicide Undetermined1:1 Pending QW Circumstances Investigation Medical Certifier Name Title Carrie Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 85 EiBurial Date Cemetery,Crematory or Facility Name 10/16/2020 Pine View Crematory ❑Entombment Address lCremation Queensbury Town,New York 0 Donation O Removal Date Place Removed F and/or and/or Held N Hold Address 0 IL i—i ( L j Transportation Date Point of ES Common Shipment Carrier Destination 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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above • Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/15/2020 Registrar of Vital Statistics Aimee Mahoney(ECectronica((y Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i— W Date of Disposition i41 7/ Q Place of Disposition pil,e.► V�� (�' e1 r ry 2 Y (address) W N CC (section) (lot number) (grave number) 0 Name of Sexton or Person in Charge of Premises J c.r/11 t,y cS tf,,rc,S z (please print/ W Signature "Vig.: Title Cr re,►nc:.rdc7r DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 0111 I Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#