Rozell, Sandra NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit PermitIName First Middle Last Sex
Sandra M. Rozell Female
Date of Death Age If Veteran of U.S.Armed Forces,
i, October 14, 2015 76 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
G Manner of Death 1:1Natural Cause lili Accident El Homicide 0 Suicide 0 Undetermined Pending
W Circumstances Investigation
0 Medical Certifier Name Title
al Ruth Scribner Coroner
Address 55 Beckett Road Whitehall New York 12887
Death Certificate Filed District Number z��b Registerumber
City,Town or Village Whitehall tJ :J
❑Burial Date October 19, 2015 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
z EN Cremation Quaker Road Queensbury New York 12803
Date Place Removed
0 Ei Removal and/or Held
ro and/or Address
I" Hold
0 Date Point of
00 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a0 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
I- Name of Funeral Firm Making Disposition or to Whom
a Remains are Shipped, If Other than Above
W Address
a.
Permission is hereby granted to dispose of the human remains described above.
as indicated.
Date Issued 10- /( - /5 Registrar of Vital Statistics �`��,t,l,e a Q. rThlki t
i (signature)
District Number 5°1tP 4 Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Z ft.t
WDate of Disposition /ofi(.IW Place of Disposition tL � or"2 ( dress)
W
Q
0 (section) i (-(lot number) (grave number)
d Name of Sexton or Person in Charge of Premises i4r., [n"fr
Z L
1 (please print)
W d Title ' I(
Signature ,
(over)
DOH-1555 (02/2004)