Bodensieck, Rosemary NEW YORK STATE DEPARTMENT OF HEALTH _
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Rosemary Bodensieck Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/18/2023 0 years War or Dates
Place of Death Hospital, Institution or
Z City, T19(x9QX( Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
W Circumstances Investigation
W Medical Certifier Name Title
Danielle Goertzen MD
Address
90 South Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number .
City, T %MOM Glens Falls 5601 1
0 Burial Date Cemetery or Crematory
01/23/2023 Pine View Cematory
OEntombment Address
ii L Cremation Queensbury, Ny
Date Place Removed
Z 0 Removal and/or Held
2 and/or Address
k= Hold
CA
Date Point of
Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home 01079
Address
82 Broadway Fort Edward, Ny
Name of Funeral Firm Making Disposition or to Whom
.�. Remains are Shipped, If Other than Above
21 Address
CC
Ili
Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued 01/23/2023 Registrar of Vital Statistics
(signature
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
%f A
t� Date of Disposition � � I jzyiy3Place of Disposition --t
(address)
tit
(section) (lot number) (grave number)
ei Name of Sexton or Pers in Charge of Premises /1„41-_, 'T
Z. (pase print)
Signature Title fn(m s;pa
(over)
DOH-1555 (02/2004)
1 1 6 62`7
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#