Rockwell, Clarence NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clarence George Rockwell Male
Date of Death Age If Veteran of U.S. Armed Forces,
• May 19, 2012 86 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Fri.i Natural Cause 0 Accident E Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
C' Thomas Hafer, Dr.
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Numbed Regist r Number
City, Town or Village Fort Edward 5'25-- D
®Burial Date Cemetery or Crematory
May 23, 2012 St. Alphonsus Cemetery
_:;'❑Entombment
Address
El Cremation Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A
Permission is he eby anted to dispose of the human ins described ove a indicated.
Date Issue. „2 1,1_ Registrar of Vital Statisti
_---/----- (signature)
41 District Nu er Place / 171
J' " 4/,,id
,,
,.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/23/2012 Place of Disposition Queensbury,NY 12804
(address)
2 3
(s do ) (lot num er) Q (grave number)
Name of Se erson in Charge of Premises �� t� '\
(please punt)
Signature Title `�� �'/
(over)
DOH-1555 (02/2004)