Rozell, Robert NEW YORK STATE DEPARTMENT OF HEALT
Vital Records Section A Burial - Transit Permit
' ` N• ame First
ks Middle li Last Sex
Robert James i Rozell Male
" D• ate of Death Age If Veteran of U.S. Armed Forces,
%,' February 13,2018 89 War or Dates Marines
, Place of Death
` ..,_.,.blospital, Institution or
City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause [Accident ❑Homicide ❑Suicide n Undetermined Pending
° Circumstances Investigation
Medical Certifier Name Title
Eric Goe,MD
Address
Glens Falls,NY
, Death Certificate Filed District Number Register Number Qn
City, Town or Village Glens Falls,NY 5601 U p(
❑Burial Date Cemetery or Crematory
❑Entombment February 14,2018 Pine View Crematory
Address
®Cremation Queensbury,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
V)
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
II
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
16 Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
5 Address
Tv Permission is hereby ranted to dispose of the human remains descr'bed bo a��ated.
�. Date Issued Registrar of Vital Statistics
/ //// (signature)
District Number 0/ Place �%ec� �6`5, tiY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
im Date of Disposition )I1$I10,1 S Place of Disposition pot, (/;,G� crY.
c;a
2 (address)
couu
O (section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises �.,f M<,y Sri,;r cs
Z (please print)
Signature //., 4`,,.., Title C fi Ai k4vr
(over)
DOH-1555(02/2004)