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Rozell, Mark 4 3(1NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 111 Name First p'` ,� 4,Q k Middle Last )0 bZE-a- iiiiiiii v4 Date of Death / Ages 7 If Veteran of U.S. Armed Forces, CD - id -0401/ ,Jlo War or Dates A. Place of Death �t Hospital, Institutio o City, Town or Village Street Address i�l Z�'JO"P( S-77Z .T. 1 Manner of Death❑Natural Cause ❑Accident Homicide 14 Suicide 17 Undetermined El Pending Circumstances Investigation iii Medical Certifier Na Title rLi vidri49 a Death Certificate Filedi. L., District Number Register Number ..... 55. —(3e.tkect Ras \A5-uArt-tuu PY. Igq-‘ .ii1 City, Town or Village nifil Dat or e c '❑Burial /p _22i` �6 r / *eteVy e iity ol( ite, (.5)©Cremation Address uCLIWL-(d Qug , kou"! Date I Place Removed , Z Removal ❑ and/or Held and/or Address Hold Date Point of Q Transportation , Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to ) A A Name of Funeral Home u vyI1u ai tt4 1l2) ( U,,A0*()P R egistd/ 7N ber 111 • ' Address 1 ' --6/e - t =i et. , N y id&6 ` — >' Name of Funeral Firm Making Disposi ion or to Whom Remains are Shipped, If Other than Above Address '< Permission is hereby granted to dispose of the human remains describe above as indicated. iiiiiii? Date Issued 0/41241,// Registrar of Vital Statistics C !' (signature) District Number 5-7 6 Place az€- --i I ` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- n �+ WDate of Disposition t• hi It( Place of Disposition �,..eUrC'u (. 4o* � 2 (address) W N le (section) (lioIt,,n�.umber.'` (grave number) Name of Sexton or Perso in Charge of P emises Ci Lkr°S�"1'r Je v *r('t Z (please print) ``i Signature L Title CR Erwd og. (over) DOH-1555 (9/98)