Rohm, Kathleen 1 )11/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen J. Rohm Female
Date of Death Age If Veteran of U.S.Armed Forces,
May 3,2012 69 War or Dates
i_ Place of Death Hospital, Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death X Natural Cause Accident Homicide I I Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Robert W.Sponzo MD
Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Num r
City, Town or Village Glens Falls,NY 5601 020
❑Burial Date Cemetery or Crematory
Entombment May 8,2012 Pine View Crematory
Address
t Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
t- Remains are Shipped, If Other than Above
t Address
a Permission is hereby granted to dispose of the humaiQemains describ above as i ' d.
Date Issued 5-4-12 Registrar of Vital Statistics d(,e�'�s-t ,( f
( gnature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 5'S tit Place of Disposition ( erg
d (address)
N
re (section) (lot numbs (grave number)
pName of Sexton or Person in Charg f Premises (f,,tti - v(A'
Z ji�^ �. (please print)
Signature ( ? Title q�Lt=��►1f�rtr) 1.
tl (over)
DOH-1555(02/2004)