Rock, Ronald NEW YORK STATE DEPARTMENT OF HEALTH t q,35-
Vital Records Section Burial - Transit Permit
Itt Name First Middle Last Sex
Ronald Paul Rock Male
0 Date of Death Age If Veteran of U.S. Armed Forces,
June 11, 2016 65 War or Dates
1'41; Place of Death Hospital, Institution or
City, Town or ilia• sur FA Street Address
1=1 Manner of Deat El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide Undetermined El Pending
ti! Circumstances Investigation
W Medical Certifier Name Title
Gt Philip J Gara Jr. MD,
F Address
327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
Ar City, Town or Village --7)G /S
❑Burial Date Cemetery or Crematorye June 15, 2016 Pine View Crematorium
❑Entombment Address
1 ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zRemoval and/or Held
and/or Address
Hold Union Cemetery
0 Date Point of
c`0 Transportation Shipment
10 by Common Destination
Ea Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
f Y'; Permit Issued to Registration Number
.5` Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2' Address
W..
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued G //,-(//6 Registrar of Vital Statistics ei ,T 6,u-. ,,.
(signature)
' District Number Place '.roil / /Is
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
y Date of Disposition 06/15/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W'
ft (section) /��/ (lot number) (grave number)
Name of Sexton or Person in Char a of Premises G ti naj7- ct,4-
� (please print)
W Signature Crt Titleb'1114
(over)
DOH-1555 (02/2004)