Weller, Roxanne NEW YORK STATE DEPARTMENT OF HF,�ALTHIlt (II
Burial - Transit
Vital Records SectionPermit
Name First Middle Last Sex
Roxanne Marie Theresa Weller Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 4, 2013 72 War or Dates
ZPlace of Death Hospital, Institution or
City, Town or Village Wilton Street Address 445 Wilton/Gansevoort Road
', Manner of Death 1 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U Circumstances Investigation
WW Medical Certifier Name Title
I Michael Adams MD,
Address
Moreau Family Health Ctr S. Glens Falls, NY
Death.-Ceftr iti~ate Filed District Number Register Number
( CityLow Village \Ai i I +)Y) Lf 51, 5
❑Burial Date Cemetery or Crematory
August 5, 2013 Pine View Crematorium
❑Entombment Address
- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
0 Date Point of
1 ❑Transportation Shipment
l6 by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
UI
a" Permission is hereby granted to dispose of the human remai s described abov as indicated.
0
Date Issued j /2O 0Registrar of Vitai Statistics (,� d� ��'(signature)
District Number Place /7 & ta/117/0
. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tij Date of Disposition '/(,l i3 Place of Disposition 'l'oe.Ua144 Cfr�m<'I o!'cco"—
Ili (address)
CO
(section) (lot mber) e (grave number)
0 Name of Sexton or Person in Charge of Pr mises flip j r ,. 1+r.4/
z (please prii
W Signature Title CIll' PrtOy2
(over)
DOH-1555 (02/2004)