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Rose, Jean L • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle ' Last Sex Jean L. Rose Female Date of Death Age If Veteran of U.S.Armed Forces, 04/25/2021 97 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing W p Manner of Death © Natural Cause El Accident El Homicide ❑Suicide Undetermined ❑Pending U Circumstances Investigation W Medical Certifier Name Title 0 Leonard Gelman MD Address 17 Madison St,Granville Village, New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 21 ElBurial Date Cemetery,Crematory or Facility Name 04/27/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town, New York ❑Donation Removal Date Place Removed and/or and/or Held - Hold Address N 0 a Date Point of U) 1-1 Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 5 Address CC uJ a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/27/2021 Registrar of Vital Statistics Fich=rdRatgts(Elafrcridly.gnai) (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition 'kg/'j.1 Place of Disposition 4 '.� Lt 0 11.1 2 (address) W CC (section) /t1'lot number) (grave number) gName of Sexton or Person in Charge of Premises Z (pleas rint) W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014744, Receipt Human remains of delivered on 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#