LaRose, Ida tt
NEW YORK STATE DEPARTMENT OF HEALTH ( 1 fuS
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ida May LaRose Female
Date of Death Age If Veteran of U.S.Armed Forces,
,. September 24, 2015 73 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Saratoga Springs Street Address Saratoga Hospital
G Manner of Death Q Natural Cause El Accident El Homicide El Suicide E Undetermined El Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Dr. Rodney Ying, M.D. Dr.
a Address
59 Myrtle, Saratoga, NY
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs i-I. C31
'Li
❑Burial Date Cemetery or Crematory
September 29, 2015 Pineview Crematorium
❑Entombment Address
Cremation Queensbury, NY 12804
2 Date Place Removed
0 El Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
El 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
x• Remains are Shipped,If Other than Above
W Address
0.
Permission is he by g anted to dispose of the human remains described above as indicated.
Date Issued C 2B j Registrar of Vital Statistics trkv..N _ --11(A.44
signature)
District Number L jc4 Place Saratoga Springs,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 09/29/2015 Place of Disposition Pineview Crematorium
2 (address)
Ill
1
I
0 (section) of number) (grave number)
0 Name of Sexton or Person in Charge f Premises (l hr 1,. Sli't4t
W /�, (plese print)
Signature !o'[. Title 11ZE `1Z�
(over)
DOH-1555 (02/2004)