Rushia, Ronald NEW YORK STATE DEPARTMENT OF HEALTH 4 Z 6S
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ronald F. Rushia Male
Date of Death Age If Veteran of U.S.Armed Forces,
1. June 1, 2011 67 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death 0 Natural Cause Accident El Homicide ElSuicide Undetermined lip Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Gamal Rhalifa, M.D. Dr.
Q Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls ..c.60 j 2 r -2
❑Burial Date Cemetery or Crematory
June 3, 2011 Pineview Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
Q0 Removal and/or Held
and/or Address
Hold
Date Point of
0 Ej Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a0 Disinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IX
W Address
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 61 Z/ f I Registrar of Vital Statistics "ems lAkiLikArk. U ..k I C
(signature)
District Number .560 / Place Glens Falls,New York
I
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 06/03/2011 Place of Disposition Pineview Crematorium
2 (address)
LI
It
(section)( ) a
Opt number,}.. (grave number)
ZName of Sexton or Perso i Charge of Pr ises f,Stc�R,r H��
W (please print)
Signature Title Ci
9 Z �
(over)
DOH-1555 (02/2004)