Rozell, Joyce NEW YORK STATE DEPARTMENT OF HEALTH ' t Tt 5 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
I Joyce Leona Rozell Female
.414 Date of Death Age If Veteran of U.S. Armed Forces,
r 8/4/2016 10 WarorDates No
Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 64 Pearl Street
Manner of Death )wiNatural Cause ❑ Accident E Homicide El Suicide ❑ Undetermined ❑ Pending
; Circumstances Investigation
Medical Certifier Name Title
Cherie A. Coe FNP
r Address
3� 3 Irongate Center, Glens Falls, NY 12801
,ssDeath Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 57 ,(o ./d
6 0 Burial Date Cemetery or Crematory
8/5/2016 Pine View Crematory
0 Entombment Address
s['Cremation Queensbury, NY 12804
Date Place Removed
1-1❑ 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 R gqistration Number
s Name of Funeral Home M.B. Kl lmer Funeral Home 0107 8
Address
as 136 Main St. So. Glens Falls, NY
Sir Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.' Address
Q,
,
r Permission is hereby granted to dispose of the human described above as indicated.
Date Issued 8/5/2016 Registrar of Vital Statistics ° "
(signature)
District Number 57 vt, Place Hudson Falls, NY
soil-
4.
Kt I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ri n
Date of Disposition 4OO(1b Place of Disposition fintOw.) Ci+w ^.-�
(address)
a
(section) //(lot number) (grave number)
n
' Name of Sexton or Person in C arge of Premises rdr J
a ( lease print)
00'' -
Signature Title
(over)
DOH-1555 (02/2004)