Rozelle, Sandra Jean COit KQ-)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sandra Jean Rozelle Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/13/2022 71 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 1895 State Route 9,Lake George Town,New York 12845
p Manner of Death ill Natural Cause Accident 0 Homicide ESuicide ❑Undetermined ri Pending
W
U Circumstances Investigation
LU C Medical Certifier Name Title
Robert Reeves MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Lake George District Number Register Number
City,Town or Village 5651 11
Burial Date Cemetery,Crematory or Facility Name
05/17/2022 Pine View Crematory
)Entombment Address
Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
CO EITransportation
p by Common Shipment
-
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
— Remains are Shipped,If Other than Above
N Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/17/2022 Registrar of Vital Statistics Patricia RMdK(inney-Sc/iuster(E(ectronicallySigned)
(signature)
District Number 5651 Place Town Of Lake George
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z fj
t!V Date of Disposition S�g lZ Place of Disposition �,u� ,--
2 (address)
W
U) (section) (lot number) sob
(grave number)
g Name of Sexton or Person in Ch a of Premises d
et (lot
Z (p se print) tt
W Signature Title l rl/ ►fi'1
DOH-1555(07/18)p 1 of 2
M
Public Health Law Sec. 4145(2b)
Receipt
Human remains of " `. delivered on • , 20
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#