Stewart, Rose 1 ; J
NEW YORK STATE DEPARTMENT OF HEALTH 4Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Rose Ora Stewart Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 4,2012 I 77 , War or Dates 1957-1964
Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Piines Of Glens Falls
• Manner of Death j Natural Cause U Accident E Homicide n Suicide ❑Undetermined Pending
b3� Circumstances Investigation
Medical Certifier Name Title
g' Susanne Rayeski Dr.
Address
aaj 3767 Main Street,Warrensburg,NY 12885
, Death Certificate Filed District Numbe5601 Register Number
• City, Town or Village Glens Falls L) 5 el
❑Burial Date Cemetery or Crematory
❑Entombment October 10, 2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Date Cemetery Address
n Disinterment
p i
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
1; Remains are Shipped, If Other than Above
Address
Cii
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued .) / 51 1 'Z. Registrar of Vital Statistics (
(signature)
District Number 5601 Place Glens Falls) 9V V 12%01
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 10/10 lit Place of Disposition ,�Gr�•t/6a.f (/cri►►c 4rtt.-
W (address)
Cl)
C (section) (lot number) (grave number)
p Name of Sexton or Person in Charg of Premises �(;,) r Se.ta -
Z (pl se print)
W Signature4 Title e ►iii-roit
(over)
DOH-1555(02/2004)