Rozell, Sandra NEW YORK STATE DEPARTMENT OF HEALTH '` 700
$
Vital Records Section ' Burial - Transit Permit
Name First Middle Last Sex
Sandra Ann Rozell Female
Date of Death Age If Veteran of U.S. Armed Forces,
4-1 -1 3 68 War or Dates NO
Place of Death City of GlensFalls Hospital, Institution or Glens Falls He' tal
City, Town or Village Street Address P
Manner of Death Ej Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael iller MD
Address
100 Park St. Glens Falls New York 12801
Death Certificate Filed City of Glens District Number Register Number
City, Town or Village Falls 560 )
J a g
❑Burial Date Cemetery or Crematory
[]Entombment 4 8 1 3 Pine View Crematnry
Address
®Cremation 21 Quaker Road Qneenshliry, New York 12804
Date Place Removed
ni Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date emetery Address
EReinterment Date emetery Address
Permit Issued to M. B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01 078
Address
136 Main St. South Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued Li 1 Z //_3 Registrar of Vital Statistics I,fvc.). Q,t.n3
(signature
District Number. / Place 6(SLN^S VU \,‘,5 J jJ y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition q•1-1 j Place of Disposition 'i.41.1%,.i (0,,m pr.w-
(address)
(section) 4 (lot number) (grave number)
Name of Sexton or Person in Charge f Premises ,, L. 'iAi
((please print)
Signature _ /If Title (TEM IrtAL
(over)
DOH-1555 (02/2004)