Rose, Ellene NEW YORK STATE DEPARTMENT OF HEALTH in
Vital Records Section Burial - Transit Permit
:f▪:▪ Name First Middle Last Sex
:fir' Ellene Frances Rose Female
?;. Date of Death Age If Veteran of U.S. Armed Forces,
:rr. October 29, 2015 95 War or Dates n/a
iPlace of Death Hospital, Institution or
City, Town or Village Granville Street Address Indian River Nursing Home
gi Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name , Title
:rr 1 hOtimC--S / 0-rc1,0i W 0
Address
: ? Death Certificate Filed District Number Register Number
�� City, Town or Village W
r :. 9 Granville, NY 5725
❑Burial Date Cemetery or Crematory
El Entombment November 2, 2015 Pine View Crematory
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
yTransportation Shipment
Q by Common Destination
Carrier
n Disinterment Date Cemetery Address
I Reinterment Date Cemetery Address
fr; Permit Issued to Registration Number
:, Name of Funeral Home Regan Denny Stafford Funeral Home 01443
r Address
r. 53 Quaker Road, Queensbury,NY 12804
r;: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is her
e by anted to dispose of the human remai de bo indicated.
f; Date Issued /9 Registrar of Vital Statistics
c
(signature)
District NumberIO0— Place •O
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
Z
uI Date of Disposition 11/3(j5 Place of Disposition 'Ftid,.i C,.,„w-fe;,,..-
2 (address)
W
N
(section) (lot number (grave number)
ZName of Sexton or Person in Ch ge of Premises (,(� 3t,.,nt
Z (please print)
Signature /il Title ()mai_
(over)
DOH-1555(02/2004)