Rosell, Martha NEW YORK STATE DEPARTMENT OF HEALl1-1 ie' G0
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
Martha Sylvia Rosell Female
.:. Date of Death Age If Veteran of U.S. Armed Forces,
September 25, 2014 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address House Of Grace
gl Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
I Medical Certifier Name Title
William Tedesco Dr.
Address
3 Irongate Center,Glens Falls,NY 12801
:;a;: Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 X.57
❑Burial Date Cemetery or Crematory
❑Entombment September 29, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F Hold
Cl)
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
'•::: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
:7'' 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des ab ve icated.
.Y. ./ifl
Date Issued t9/•Nr�.�lY Registrar of Vital Statistics
(signature)
... District Number 5601 Place Glens Falls / ! /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Brij~ Place of Disposition t✓ 6• w-
W (address)
U)
p0 (section) //�� (lot rynber) (grave number)
Name of Sexton or Person in Charge of Premises t^rrsT Lr. "''�'
'Z (please print)
Signature A4Title CIleeltflif
(over)
DOH-1555(02/2004) i