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Rose, Jane E NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex Jane E. Rose Female ... .................:.:.....::..:.........:::.:.......:::.;..........., .... .................... ..... ..... ....... ..... ... ................. Date of Death Age If Veteran of U.S.Armed Forces, 1/12/91 67 War or Dates No . ..........:.. Z Place of Death Hospital, Institution or LU City,Town or Village Saratoga Springs Street Address Saratoga Hospital Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Ei Pending Circumstances Investigation .. .............. ..................................._ .: ........................................ ................. W Medical Certifier Ne Title G Robert Pringle ND _..... . ,........ .... .................................. ...... .......... .. _.... ........ ............... .. ...... .... ......... ......... ..... _. Address Saratoga Springs NY ...............:.... :.... ..................................................... ....::...... .: .: :::::....::-:::.. .... ........ ...... Death Certificate Filed District Nu b r Register Number City,Town or Village Saratoga Springs W�01 Date Cemetery or Crematory ❑Burial Jan. 14, 1991 Fine View Crematorium ......... . ..... ....... ..... -... ............... .. ®Cremation Address Town og Queensbury, NY ... . .... Z Date Place Removed O Removal a and/or Held and/or Hold ::..... .................:....................... ......:. ... .......::.... _ ..:: .......... Address ........ .:::..... .. o: Date Point of Ln Transportation by Shipment a Common Carrier ........ ... .......- Destination ........ ................... _ .:. .: _ Disinterment Date Cemetery Address ............................... .... .... El Reinterment Date Cemetery Address Permit Issued to Registration Num er Name of Funeral Firm William J. Burke & Sons Funeral Home 00W ........ .:::......-- .::: ............ .. ._.... _._ _... Address Saratoga Springs, NY 12866 .......................... ................................. ...... . . ..::: .. ...... _.. f—: Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above :..: .... ..... ... ... _ .............. t11: Address a< .... _...... ...................... ...9:,: ....... .....: ......... .:: t::.._. Permission is herebyranted to dispose of the hu r m in descn ed�ae ed. Date Issued1l191Registrar of Vital Statistics l /' ., (signature) 4501 Saratoga. Springs, NY District Number Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZI Date of Disposition "/ Place of Disposition/4//� 2 (address) W' tn` (section) (lot number) (grave number) � p'' Name of Sexton r Person i Charge of Pre ises ,......................--e.....j.I...................................................... ...................I--...... p -� , / W (Please print) ���/YI// l��Y / / e Signature Title DOH-1555 (10/89) p. 1 of 2 VS-61