Brock, Roxanne A
testis-
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
;rf Name First Middle Last Sex
s: Roxanne Brock Female
Date of Death Age If Veteran of U.S. Armed Forces,
':':: September 16, 2014 64 War or Dates
Ii. Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The House Of Grace
Manner of Death X Natural Cause Accident I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Darci Gaiotti Grubbs Dr.
•;f Address
102 Park St,Glens Falls,NY 12801
}r Death Certificate Filed District Number Register Number
r: City, Town or Village Glens Falls 5601 LI `" t f
❑Burial Date Cemetery or Crematory
❑Entombment September 17, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
,i— Hold
CO
O Date Point of
N1 1 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Iti Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Me M
{rr'▪r Name of Funeral Firm Making Disposition or to Whom
I" Remains are Shipped, If Other than Above
Address
:•,.:, Permission is hereby granted to dispose of the human remains described above as indicated.
▪ Date Issued 9 l j g I f q Registrar of Vital Statistics Lk)0.A...t_ty-,12 LA.02...A-J'eCt
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above wer isposed of in accor nce with this permit on:
Z
W Date of Disposition 9 / — ilI Place of Disposition //WI VaA/1 io/h'.y
2 (address)
W
N
fY
(section) SO-e).14
(I mber� � (grave number)
Z Name of Sexto orb;er in harg of Premises S�//3,�
W .sr �;ant) /Signatu ►) _ Title 4 7 -
(over)
DOH-1555(02/2004)