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Rockwell, Scott NEW YORK STATE DEPARTMENT OF HEALTH (f 75 Vital Records Section Burial - Transit Permit Name First Middle Last I Sex Scott Alan Rockwell ! Male Date of Death ! Age If Veteran of U.S. Armed Forces, 11111111111 06/20/2015 1 50 yrs. War or Dates No Place of Death Town of Hague Hospital, Institution or 5 Sno Pappy Lane City, Town or Village 1 Street Address liJc© Manner of Death go j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑ Pending LU Circumstances Investigation W Medical Certifier Name Title Paul Bachman M.D. Address 3767 Main Street, Warrensburg, NY 12885 Death Certificate Filed District Number i Register Number City, Town or Village Town of Hague j 5653 ! 3 Date Cemetery or Crematory ❑Burial 06/26/2015 Pine View Crematory Address Cremation Queensbury, New York Date Place Removed 0❑ Removal and/or Held -- and/orHold Address 0 0 Date Point of N ❑Transportation j Shipment a by Common Destination Carrier Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to 1 Registration Number Name of Funeral Home Wilcox & Regan Funeral Home 01821 IN Address 11111111111 11 Algonkin St., Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above >04 Address 1U 4, IM Permission is hereby granted to dispose of the human remains described above as ind.cated. Date Issued 06/23/2015 Registrar of Vital Statistics 9` k..._ on ► n (sign ure) District Number 5653 Place Town of Hague I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition `oi -30--/S Place of Disposition 1 1 n-e o e CC4tv14r4or Urn 2 (address) uJ CC (section) . ,`� (lot number) (grave number) GName of Sexton or Person in Ch. ge of Premises _ I I'm r ( npi g ... (please print) f W Signature dcrynr Title CreAna;{cry /4 4 (over) DOH-1555 (9/98)