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Roselle, Lila V
F. •i6-11 NEW YORKSTATE DEPARTMENT OF HEALTH Burial- Transit Permit Bureau of Vital Records • Name First Middle Last Sex Lila V Roselle Female Date of Death Age If Veteran of U.S.Armed Forces, 07/13/2023 38 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village South Glens Falls Village Street Address 189 Main Street 6,South Glens Falls Village,New York 12803 p Manner of Death ❑Natural Cause Accident Homicide Suicide FlUndetermined RIPending W0 Circumstances Investigation W Medical Certifier Name Title II David DeCelle Coroner Address 40 McMaster Street,Ballston Spa,New York 12020 Death Certificate Filed Village Of South Glens Falls District Number Register Number City,Town or Village 4524 14 Burial Date Cemetery,Crematory or Facility Name 07/15/2023 Pineview Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation ZO E1 Removal Date Place Removed and/or and/or Held t- Hold Address CO aDate Point of W Transportation Shipment S by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 5 Address Ir W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/14/2023 Registrar of Vital Statistics Samantha Berg(Electronically Signed) (signature) District Number 4524 Place Village Of South Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:II— , A Date of Disposition 7111 17> Place of Disposition N V L.err 2 (address) W CC (se t nn) (/ot number) (grave number) SName of Sexton or Person in Charge P ises r, L�_ tt z ease print) p W Signature �. Title I 6 14 1014 DOH-1555(07/18)p id 2 1 k i., f 1. 4�6 Public Health Law Sec. 4145(2b) Receipt Human remains of I< delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#