Rocque, Cole NEW YORK STATE DEPARTMENT OF HEALTH r ir: 1 It ( J
Vital Records Section Burial - Transit Permi
Name First Middle Last Sex
Cole M Rocque Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 6,2011 20 War or Dates
N Place of Death Hospital, Institution or
City, Town or Village Troy Street Address 2221 15th Street
WManner of Death Natural Cause Accident I 'Homicide X Suicide Undetermined Pending
Circumstances Investigation
Au Medical Certifier Name Title
a Michael Sikirica,MD Rensselaer Co. Medical Examiner
Address
50 Broad Street.,Rensselaer,NY 122144
Death Certificate Filed District Number Register Number
City, Town or Village City of Troy 4102 /54
❑Burial Date Cemetery or Crematory
MArch 14, 2011 Pine View Crematory
❑Entombment Address
OCCremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
j Reinterment Date Cemetery Address
< Permit Issued to Registration Number
na Name of Funeral Home Jillson Funeral Home, Inc 00897
Address
46 Williams Street, Whitehall, NY 12887 ___
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
2 Address
df
Lu
EL
Permission is hereby granted to dispose of the human remains described above as indicated.
ri Date Issued 3/8/2011 Registrar of Vital Statistics efiddfrit. E &-C...a.,t&
(signature)
-x4 District Number 4102 Place City of Troy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition .- ib-ii Place of Disposition -PMUN 60.4.chir11,•.,
5 (address)
W
N
re (section) (lot number) (grave number)
QName of Sexton or Pers n in Charge of remises r,Sr1oDhct &lid-
`Z TT (please print)
Signature I L, Title C(2C.Jh�I-0IL
(over)
DOH-1555 (02/2004)