Sears, Rosalie NEW YORK STATE DEPARTMENT OF HEALTH f ,,, 4 3 v Z.
Vital Records SectionBurial - Transit Permit
Name First Middle Last Sex
Rosalie Cora Sears Female
r Date of Death Age If Veteran of U.S. Armed Forces,
June 15, 2013 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address
Manner of Death❑ Undetermined Pending X Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ ❑
Circumstances Investigation
Medical Certifier Name Title
William Borgos, M.D. Dr.
Address
161 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number ��i RegistD )er
City, `
Town or Village 1
❑Burial Date Cemetery or Crematory
June 17, 2013 Pine View Crematory
❑Entombment Address
s n®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
4 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
,-= Name of Funeral Home M. B. Kilmer Funeral Home 01079
Address
a 82 Broadway, Fort Edward NY 12828
G Name of Funeral Firm Making Disposition or to Whom
w. Remains are Shipped, If Other than Above
• Address
Permission is her by granted to dispose of the humanfemains cribed ab ve as indicate .
Date Issued Registrar of Vital Statistics Q7_,2—e__--f-) • .
(signature))
District Number 5Zpn 7 Place „_... /17:_-2€<1
I certify that the remains of the decedent identified above were disposed of in accordance with th' permit on:
Date of Disposition 06/17/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) _(lot umber) c (grave number)
Name of Sexton or Per +n in Charge o Premises i r enytt
( ease print)
' L. •,/
SignatureTitle rilk 0 ink
(over)
DOH-1555 (02/2004)