Rozelle, Doris NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Doris D Rozelle Female
ni Date of Death Age If Veteran of U.S. Armed Forces,
07/10/0011 90 years War or Dates
144 Place of Death Hospital, Institution or
CityILI , TowiJi Glens Falls Street Address Glens Falls Hospital
0 Manner of Death L. Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
ta Medical Certifier Name Title
Suzanne M. Rayeski M n
Address
Warrensburg Health Center Main St. Warrensburg, NY
Iiigi Death Certificate Filed District Number Register Number
City, Towimilikankx C;Ians Falls 5601 60
❑Burial Date Cemetery or Crematory
❑Entombment 07/14/201 3 Pine View Crematorium
Address
❑Cjemation Queensbury. NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address
w" Hold
0
0 Date Point of
IL 0 Transportation Shipment
is by Common Destination
Carrier _
❑Disinterment Date Cemetery Address
.: LI Reinterment Date Cemetery Address
Iiii Permit Issued to. Registration Number
40 Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address .
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
I
I LI
: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/11/2013 Registrar of Vital Statistics (A.;C.A U0. k--"
(signature)
'' District Number Place
5601 Glens Falls
'" I certify that the remains of the decedent identified above were disposed of inn�accordance with this permit on:
ILI Date of Disposition 2-I1"13 Place of Disposition -I' 4Utti") CI-Am kw►_.
i `
X (address)
U)
l (section) (lot number) (grave number)
CI• Name of Sexton or Person in Charg of Premises di: ✓!n^41
zr I (please print)
• Signature471.,-- Title «► tet
(over)
DOH-1555 (02/2004)