Nonkin, Rose NEW YORK STATE DEPARTMENT OF HEALTH 4 :1
Vital Records Section ¢ t Burial - Transitrermit
h
, Name First Middle Last Sex
f. .
''U Rose Nonkin Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 25, 2013 91 War or Dates
.,. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 27 Woodvale Rd.
Manner of Death X Natural Cause ❑Accident U Homicide Suicide Undetermined Pending
tfi Circumstances Investigation
Medical Certifier Name Title
Dr.Paul Filion MD
Address
Death Certificate Filed District Number Regjter Number
City, Town or Village Queensbury Queensbury ��
❑Burial Date Cemetery or Crematory
May 28, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
u) n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
_ :
Permission is herebygranted to dispose of the human re sins described abpv as indicated.
Date Issued 1 c)t laOJ Registrar of Vital Statistics �6.— f
(signature)
District Number Queensbury Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to a1(3 Place of Disposition —434. PwJ acid/iv+�
2 (address)
W
Cl)
cc (section) pt nl�m er) (grave number)
pName of Sexton or Person in Charge of Premises hrts t gLh14it
Z (please rint)
W 1,�� Title CIZ M (t
Signature
(over)
DOH-1555(02/2004)