Rozell, Robert J II so
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
gogfiP'j J Rozell Male
Date of Death Age If Veteran of U.S.Armed Forces,
F. October 31, 2018 57 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Home
G Manner of Death n Natural Cause ❑ Accident n Homicide 0 Suicide 0 Undetermined ❑ Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Christopher Mason Md
0 Address
102 Park Street Glens Falls NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 5'758 5
n Burial Date Cemetery or Crematory
November 5, 2018 Pineview Crematorium
n Entombment Address
2 ❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
- and/or Address
I' Hold
(I) Date Point of
0 n Transportation Shipment
d by Common Destination
0 Carrier
Date Cemetery Address
a" E 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
F
Name of Funeral Firm Making Disposition or to Whom
ce Remains are Shipped, If Other than Above
W Address
O.
Permission is hereb granted to dispose of the hum re ains described ve as indicated.
Date Issued Oa 2 Registrar of Vital Statistic 2e(« 5-
(sign ure)
_p amp
5'7.&
District Number Place -Wtritcha4l,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 11/05/2018 Place of Disposition Pineview Crematorium
E (address)
W
N
0 (section) (lot umber) (grave number)
O Name of Sexton or Person in Charge of Premiss (f L ,S ta&.t(
z (please(print)
W
Signature S� Title l � w , .
(over)
DOH-1555 (02/2004)