Monterosso, Teresa NEW YORK STATE DEPARTMENT OF HEALTI ; G I v
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Teresa Monterosso Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/18/2012 52 War or Dates
F- Place of Death Hospital, Institution or
W
Z City, Town or Village GLENS FALLS Street Address GLENS FALLS HOSPITAL
CI Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide❑ Suicide ❑ Undetermined ❑ Pending
WLI Circumstances Investigation
W Medical Certifier Name Title
CI JOHN K. RUGGE,
Address
3767 MAIN ST. Warrensburg, NY 12885
!�th Certificate Filed District Number / /� Register N r
Town or Village 6p7-y/:S /�4f//Z- :V0( i l
❑Burial Date Cempry or Crematory . r>
12/19/2012 �P //� 4� (r--e �/ V/v i-z-,
0 Entombment Address
1 Cremation &✓e /- , ,,.-G% V i 410-1
Date Plac6 Removed
z ❑ Removal and/or Held
p and/or Address
E Hold
(7 Date Point of
a ❑Transportation Shipment
to by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
F_ Remains are Shipped, If Other than Above
2 Address
w
a. Permission is he eby granted to dispose of the human emains d ribed abo as indic ted.
Date Issued Registrar of Vital S .st. Zrj_)2_,e_./.-\ °
n ure) \..
District Number f Place c_
•
I certify that the remains of the decedent identified above were disposed of in accordance with this rmit on:
WDate of Disposition a-10'%2 Place of Disposition _f�%J Jtt� C,t.m1 P'wt,-`
2 (address)
W
0)
O (section) . (lot number) (grave number)
p Name of Sexton or Person in Charge of Pr raises �asl.-- �nn�f�
Z _ (please print)
W Signature Title CM',Fr Q-
(over)
DOH-1555(02/2004)