Rogers, Maria NEW YORK STATE DEPARTMENT OF HEALTH 1 q b 1
Vital Records Section t Burial - Transit Permit
Name First Middle Last Sex
Maria LaGrange Rogers Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 9, 2013 93 War or Dates
•' Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death Fri
Natural Cause ❑ Accident ❑Homicide ❑ Suicide n Undetermined pi❑ Pending
W Circumstances Investigation
�W Medical Certifier Name Title
a'' Suzanne Rayeski, D.O.
Address
170 Warren Street Glens Falls, NY 12801 ,,
Death Certificate Filed District Numb�E�` < }i Regis_ter Number
City, Town or Village ��
❑Burial Date Cemetery or Crematory
August 12, 2013 Pine View Crematorium
❑Entombment
Address
,,®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
d, and/or Address
H Hold
=
Date Point of
a ( I Transportation Shipment
by Common Destination
8 Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
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
J Remains are Shipped, If Other than Above
2 Address
W
Permission is here y ranted to dispose of the human remains des i s i ' ed.
Z Zo%3 Registrar of Vital Statistics
Date Issued 8 , g
(signature)
District Number J�,Q/ Place �A/-ei-ro j// ,
F- I certify that the remains of the decedent identified above were disposed of inaccordance with this permit on:
uj Date of Disposition gi DI r3 Place of Disposition Zak.)
ak.) C.1.%<blr+•--'
2 (address)
W
re (section)
lot number) (grave number)
0
Name of Sexton or Person i harge of Pre es r",717 ,1`- 4.efd-
c (plse print)
"" M
Signature ` L Title ���
(over)
DOH-1555 (02/2004)