Rockwell, Marguerite NEW YORK STATE DEPARTMENT OF HEALTH r Z i 20
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marguerite Mary Rockwell Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 17, 2012 90 War or Dates
WPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address
G1 Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI John Stoutenberg MD, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 02996,
❑Burial Date Cemetery or Crematory
June 20, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date I Place Removed
z ❑ Removal and/or Held
a and/or Address
F Hold
Date Point of❑Transportation Shipment
fo by Common Destination
ri Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
}— Remains are Shipped, If Other than Above
• Address
CC
I1I
11- Permission is hereby granted to dispose of the human remains descriibb d above in t d.
Date Issued �}!� �j,?l01� Registrar of Vital Statistics �/. ram/ ��
ee �
(signature)
District Number 5601 Place �/-G,-w / irl/s ,'`V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 6(2o1(1 Place of Disposition Fv4,1) J C ir )t...,
(address)
WCO
(e (section) _ (lot number) (grave number)
Z• Name of Sexton or Perso in Charge of Premises �") '' SC Irt
(please print)
W. Signature Title Crtirzrr,p'T
(over)
DOH-1555 (02/2004)