Frank, Rose --tom
NEW YORK STATE DEPARTMENT OF HEALTH I EW
Vital Records Section Burial - Transit Permit
Name First Middle • " Last Sex
Rose Frank Female
i- Date of Death Age If Veteran of U.S. Armed Forces,
March 14, 2012 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Ck„,S pas Street Address The Stanton Nusing and Rehabilitation
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
,= Circumstances Investigation
Medical Certifier Name Title
Paul F. Bachman, ME
Address
Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village "4A5-) 3
0 Burial Date Cemetery or Crematory
March 15, 2012 Pine View
-0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
f Date Place Removed
4 El Removal and/or Held
and/or Address
Hold
'gs,;41 Date Point of
DTransportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
fig,
Reinterment Date Cemetery Address
4. Permit Issued to Registration Number
• Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
• ,,: 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
a Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem 'ns descr'bed ab ve a in icated.
Date Issued 3_ 1 i „L Registrar of Vital Statistics _
(signature)
• District Number S Place �j,(I --Q-a-- -
z I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Rig Date of Disposition 03/15/2012 Place of Disposition Quaker Road Queensbury,NY 12804 I'riQ V;.:v cc dtciw°i
(address)
(section) (lot number) (grave number)
Name of Sexton or P rson in Charge of Premises :+w1e L WC
�
. 7 (please print)
Signature Title uei 401 •
(over)
DOH-1555 (02/2004)