Ciano, Rose NEW YORK STATE DEPARTMENT OF HEALTH 1 N it 3 l r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rose Ciano Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 1, 2013 92 War or Dates
i. Place of Death Hospital, Institution or
3 City, Town or Village Queensbury Street Address 6 Stonehurst Drive
Manner of Death n Natural Cause ❑Accident ❑Homicide n Suicide 1-1 Undetermined n Pending
1.41 Circumstances Investigation
2 Medical Certifier Name Title
0 Glen Anderson
Address
161 Carey Rd
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 h
❑Burial Date Cemetery or Crematory
June 4, 2013 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
t' Hold
N
Q Date Point of
as ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
t : Remains are Shipped, If Other than Above
E: Address
W
CI. Permission is hereby granted to dispose of the human rem ins escribed above a ,indicated.
Date Issued Q 1 I c3-0[4. Registrar of Vital Statistics ---... Q - ( "�-�(LC)._
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z DispositionPlace of Disposition A;174.:014.1.., ertn.ctp(Vp-
W Date of io $
2 (address)
W
U)
CL (section) li(lot number) (grave number)
Cp Name of Sexton or Pers n in Charge Premises ia},�p,"L. I hK
Z (please print)
W
Signature Title C itllT'TIP(
(over)
DOH-1555(02/2004)