Rose, Jason NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
/
—77
Name First Middle Last Sex
Jason Todd Rose Male
Date of Death Age If Veteran of U.S. Armed Forces,
,` July 29, 2015 34 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death if] Natural Cause ❑ Accident Ei Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Frances C. Bollinger, Dr.
Address
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number_ Register Number
3/4 r City, Town or Village Glens Falls 6 9J c�
0 Burial Date Cemetery or Crematory
August 3, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
:, and/or Address
Hold
Date Point of
a 0 Transportation Shipment
by Common Destination
Carrier
r ❑ Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Vil Permit Issued to Registration Number
Y Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
L.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued %/31 j, Registrar of Vital Statistics CA)Q Al.P-
(signature)
District Number 5 60 j Place 6 �S F i ( s i d✓ v
{
= I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;. Date of Disposition 08/03/2015 Place of Disposition Quaker Road Queensbury,NY 12804
,l; (address)
(section) A(lot number) (( �� (grave number)
Name of Sexton or Person in Char e of Premises �.
JW����"T��
-
(please print)
Signature v Title rirfimfrp/t
(over)
DOH-1555 (02/2004)