Rocker, Marjorie `$ -10' II 1107
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie L. Rocker Female
VDate of Death Age If Veteran of U.S. Armed Forces,
May 30,2015 87 War or Dates n/a
_ Place of Death Hospital, Institution or
City, Town or Village Queensbury,NY Street Address Westmount Health Facility
Manner of Death 0 Natural Cause 0 Accident El Homicide n Suicide ri Undetermined n Pending
Circumstances Investigation
Med' I Certifier Name Title
' s\ly- �Oc I)\ ` �
Address
aitr _-rWen ...) 1- ,-1-
Death Certificate Filed ` District Number titter Number
City, Town or Village Queensbury,NY 5657
0 Burial Date Cemetery or Crematory
❑Entombment June 2,2015 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ 11 Removal and/or Held
and/or Address
H Hold
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0 Date Point of
N E Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
0 Permit Issued to Registration Number
'tea Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
4 Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above
Address
Permission is here y granted to dispose of the human r mains described abre as indicated.
AA
w Date Issued l I Q C` ,L,-'
<r.< �(� Registrar of Vital Statistics
F .
(signature)
W
District Number i--) Place )() c.,L..-fm C)-( C....-
aI certify that the remains of the decedent identified above were disposed of in accordancett ith this permit on:
WDate of Disposition ( / ilr Place of Disposition Z v,,,, L,,.✓tor,►,
2 (address)
W
Cl)
CC (section) (lot number) S (grave number)
pName of Sexton or Person in Charge of Premises 'r1 �„ r
Z
X (pl ase print)
Signature Title /-12 97rt
(over)
DOH-1555(02/2004)