Rodd, Sally C1L!
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Re ords'ection . Burial - Transit Permit
Name First Middle Last Sex
Sally Ann Rodd Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/15/2015 76 years War or Dates
{ Place of Death Hospital, Institution or
City, Tf(xp( r (j(q�gX Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Daniel Way M. D.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, TXX105rXXIIIDO Glens Falls 5601 601
❑Burial Date Cemetery or Crematory
12/18/2015 Pine View Crematorium
❑Entombment Address
Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or
F; Address
to
Hold
0 Date Point of
piEl Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y / Z 06 3
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
,'; Address
UI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/17/2015 Registrar of Vital Statistics WCz W�^fJ
(signat e)
District Number 5601 Place Glens Falls Ni y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l• Date of Disposition i2_1$- c Place of Disposition P,yt,u reA,A, 6 re,ri4.e rr
(address)
U
CC (section) (lot number) (grave number)
Q `
• Name of Sexton or erson i harge of Premises -J k 1 r an G-frl, L 4► {_
+ ► (please print)
Signature Title 6-r'4°/1'k-iv
(over)
DOH-1555 (02/2004)