Rozell, Arlene NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
i Arlene L Rozell Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 25, 2012 66 War or Dates NO
Z Place of Death Hospital, Institution or
W City,Town,or Village Cambridge Street Address Residence
0 Manner of Death Ei Natural Cause 0 Accident 0 Homicide 0Suicide 0 Undetermined 0 Pending
illCircumstances Investigation
U Medical Certifier Name Title
W Dr. Stoutenburg MD
Q Address
102 Park Street Glens Falls New York 12801
Death Certificate Filed District Number Register umber
City,Town or Village Cambridge 5-75
0 Burial Date Cemetery or Crematory
March 28, 2012 West Glens Falls Cemetery
0 Entombment Address
❑Cremation Town of Queensbury
i Date Place Removed
0 0 Removal i and/or Held
and/or Address
F Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
al. iii Disinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
a▪ Remains are Shipped, If Other than Above
W Address
a
Permission is hereby granted to dispose of the human remains described A
above,�f� as indicated.
Date Issued ,31c37P 0/� Registrar of Vital Statistics � f (,t� , 'V�Z9 .c..c,wie4d
(signature)
District Number 5751 Place Cambridge,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 03/28/2012 Place of Disposition West Glens Falls Cemetery
2 (address)
yj Family Plot
0 (section) (lot number) (grave number)
O Name of Sexton or Person inn Charge of Premises Michael Genier
W N (please print)
Signature L, i/vvtxl•• Title Superintendent
(over)
DOH-1555 (02/2004)