Rousseau, Elroy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elroy William Rousseau Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/23/2017 85 Years War or Dates 1952-1954
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death grifi Natural Cause El Accident 0 Homicide D Suicide D Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 669
❑Burial Date Cemetery or Crematory
12/27/2017 Pine View Crematorium
['Entombment Address
NCremation Queensbury Town, New York
Date Place Removed i
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
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 12/27/2017 Registrar of Vital Statistics w96ert A Curtis cEfectronicat1ySigned
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition t2/2m//7 Place of Disposition ► 1)1€U �'',t t6' /y
(address)
(section) (lot nu ber) (grave number)
Name of Sexton or r o Charge of Premises k L '✓�- t2e, C
(please p t)
Signature �t:� ' Title C—
(over)
DOH-1555 (02/2004)