Rock, Ayashe ill -1"114
NEW YORK STATE DEPARTMENT OF-.HEALTH 51 Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ayashe Rock Male
Date of Death Age If Veteran of U.S. Armed Forces,
07 / 10 / 2015 27 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Malta Street Address
2 Arbor Ave.
Q Manner of Death❑Natural Cause 0 Accident El Homicide Suicide El Undetermined ®Pending
in Circumstances Investigation
0
ill Medical Certifier Name Title
0 Michael Sikirica MD
Address
46 McMasters St. Ballston Spa., NY
>> Death Certificate Filed District Number Register Number
°'> City,Town or Village Malta sKW 3 y
0 Burial Date Cemetery or Crematory
07 / 14 / 2015 Pine View Crematory
El Entombment
Address
Cremation 21 Quaker Road, Queensbury, NY
Dal Place Removed
Removal and/or Held
and/or Act
Hold
0 \ Point of
Q Transportatio — Shipment
C by Common at\ est
Carrier °/
o❑Disintermen,
Date Cemetery Address
ill
Q Reinterment Date Cemetery Address
mii
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
> i 402 Maple Ave., Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
tr
tU
Permission is hereby granted to dispose of the human remains described above indicated.
<'„,,,,,,,,
Date Issued I —/'R/S�Registrar of Vital Statistics G e ,,,,,aes„
(si ature)
District Number ?$4r ) Place oZs4/Ti 4.4 ' Malta , New York /2.-e 2,0
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
III
Date of Disposition iiIOC Place of Disposition Z w �i r..r�q-,�,'.
E (address)
il
CE (section) // (lot number) - (grave number)
1 �
Name of Sexton or Person ip Charge of Premises •. cSQareh'
/, ( ease print)
Signature 't/ Title CIIZPMW�
•
(over)
DOH-1555 (02/2004)