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Rozell, Richard iii -it NEW YORK STATE DEPARTMENT OF HEALTH ", Vital Records Section Burial - Trams# it Name First Middle Last _ ex Richard Rozell Male Date of Death Age If Veteran of U.S. Armed Forces, September 29, 2017 87 War or Dates Place of Death Hospital, Institution or _& City, Town or Village Argyle Street Address 114 Main Street Manner of Death Natural Cause rj Accident El Homicide Q Suicide riUndetermined r7 Pending Circumstances Investigation Medical Certifier Name Title y. Robert Lemieux, Address 219 Pope Hill Road Argyle, NY 12809 Death Certificate Filed District Number 5_, s� Register Number3 �4 City, Town or Village Argyle rE 0 Burial Date Cemetery or Crematory October 2, 2017 [l Entombment Address ©Cremation Place Removed " Removal if Date and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier a Disinterment Date Cemetery Address al 0Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home-Argyle 01077 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom - Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 55 0 Registrar of Vital Statistics j' \-° l4(c '` (signature) )4)oZ)11 5 Y District Number 519d Place y 4 +.1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 10/02/2017 Place of Disposition fRejtw A3l0t+v-- (address) (section) if (lot number) (grave number) Name of Sexton or Person in Charge of Pre 'ses (pl ase print) C( Title f ro Rom. Signature --� (over) DOH-1555(02/2004)