Rochon, Joseph Y se
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joseph Rochon Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. June 19, 2018 S 7 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 ❑Suicide n Undetermined ❑ Pending
W Circumstances Investigation
Medical Certifier Name Title
W Dr. John Stoutenberg, M.D. Dr.
a Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 57 2 O 471
❑Burial Date Cemetery or Crematory
June 21, 2018 Pineview Crematorium
n1 Entombment Address
2 I f I Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
and/or Address
l' Hold
91 Date Point of
0 n Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
5 C Disinterment
D Reinterment 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
H
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains cribed abo a dicated.
Date Issued (.o f v20 ZO(? Registrar of Vital Statistics •
l (signature)
District Number 5-72- c' Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z
W Date of Disposition 06/21/2018 Place of Disposition Pineview Crematorium
W (address)
N
0 it (section) (lot number)c (grave number)
Name of Sexton or Person in Charge of Premises ((n, Jo�►,,4
2 (pl ase print)
Wdi Signature Title eztri+nja.
(over)
DOH-1555 (02/2004)