Shattuck, Roseanna tt it
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle Last Sex
Roseanna L. Shattuck Female
Date of Death Age If Veteran of U.S.Armed Forces,
i, June 20, 2012 55 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 1.0 Natural Cause ❑ Accident ❑Homicide 0Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Aqeel Gillani, M.D. Dr.
0 Address
102 Park Street, Pruyn Pavilion, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls -‘7/ soQ
❑Burial Date Cemetery or Crematory
June 25, 2012 Pineview Crematorium
❑Entombment Address
Q Cremation Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
and/or Address
l' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
'A Carrier
0 Date Cemetery Address
0 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
it
W Address
0.
Permission is hereby granted to dispose of the hums remains scribed above as indica d.) .
Date Issued Chi„ii l,_n/ a` Registrar of Vital Statistics lfi�L .
(signature)
District Number .56a/ Place Glens Falls,New Y rk /020/
I-
I certify that the remains of the decedent identified above were di osed of in accordance with this permit on:
Z
W Date of Disposition 06/25/2012 Place of Disposition Pineview Crematorium
2 (address)
W
N
d0 (section) A (lot number) (grave number)
Name of Sexton or Person in Charge Premises a ri t r Ohetit'
Z (phase print)
W4f4.,Signature Title �¢� OIG
(over)
DOH-1555 (02/2004)