Rozell, Linda NEW YORK STATE DEPARTMENT OF HEALTH • Burial - TransitPermit
Vital Records Section
Name First Middle Last Sex
Linda M Rozell Female
Date of Death Age If Veteran of U.S.Armed Forces,
August 19, 2015 65 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
Manner of Death O Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
W Dr. Max Crossman MD
0 Address
Whitehall Health Center, Poultney St. , Whitehall, New York 12887
Death Certificate Filed District Number 5/o�0 Register Number Li
City,Town or Village Whitehall 0
❑Burial Date Cemetery or Crematory
August 21, 2015 Pineview Crematorium
❑Entombment Address
❑X Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I" Hold
Date Point of
0 ❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
5 ❑Disinterment
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human ai'ns`desc 'bed above as indi ated.
G
Date Issued 0 oit>o�)'j Registrar of Vital Statistics � tI '
(signature)
District Number 51 a g' Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
?f
w Date of Disposition 08/. '2015 Place of Disposition Pineview Crematorium
2 (address)
(t)
(section) Alo,t number) (grave number)
O Name of Sexton or Person in Charge of remises SNr
W (ple se print)
Signature Title l 1W
(over)
DOH-1555 (02/2004)