Petty, Rose NEW YORK STATE DEPARTMENT OF HEALTH if 551
Vital Records Section r Burial - Transit Permit
Name First Middle Last Sex
Rose Ella Petty Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 20, 2012 91 War or Dates
Z Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address 283 Warren St., Apt 2
WLIManner of Death Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined ri"—I Pending
O CircumstancesInvestigation
W Medical Certifier Name Title
CI William Parker, M.D. Dr.
Address
Fort Edward Hudson Headwaters Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village 56C)i L-1 T 7
❑Burial Date Cemetery or Crematory
October 22, 2012 Pine View Crematorium
❑Entombment Address
MCremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
k Hold
(7 Date Point of
d ❑Transportation Shipment
(0 by Common Destination
CI 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
2 Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued tO 2'2-� t Z Registrar of Vital Statistics
( (signature)
District Number 5 bo i Place 6 o -S \\ S u v I.) i01
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ij,i Date of Disposition jo-24-i7 Place of Disposition Y1TJVvrJ ( tot -.-
(address)
W''
G)
ie (section) 4 (lot number)r (grave number)
p ,! l�S t s. 3e0( (
• Name of Sexton or Person in Char a of Premises 1
(please print)
W` Signature /' ♦ , _ Title Ct.EMATU(L
(over)
DOH-1555 (02/2004)