Rozell, Roger NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
}▪; Roger Rozell Male
fj. Date of Death Age If Veteran of U.S. Armed Forces,
: October 13, 2014 55 War or Dates
. Place of Death Hospital, Institution or
City, Town or Village Street Address Pines At Glens Falls
Manner of Death X Natural Cause I I Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
121 Bernardo R.Villajuan Dr.
gAddress
r':%88 Broad St,Glens Falls,NY 12804
..:. Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 Li -7 S-
❑Burial Date Cemetery or Crematory
October 14, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
w
O Date Point of
NTransportation Shipment
`p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'i.,ii.5 Permit Issued to Registration Number
;rrr Name of Funeral Home Regan & Denny Funeral Home 01444
r; Address
, 94 Saratoga Avenue, South Glens Falls, NY 12803
°' r Name of Funeral Firm Making Disposition or to Whom
1 r�" Remains are Shipped, If Other than Above
� r
Address
;r::: Permission is hereby granted to dispose of the human remains described above as indicated.
:r':: Date Issued 1A/t'- 1 t '44 Registrar of Vital Statistics L.lA cum , ,
F ▪1 (signa re)
1
'`r: District Number 5601 Place Glens Falls) �)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p o� Place of Disposition - L C
w Date of Disposition f 1't�Iy ,....
2 (address)
W
U
0 (section) /� -(lot numbe (grave number)
p Name of Sexton or Person in Charge of Premises di, fib{-
Wlease print)
Signature G` 4.--,*.---"•- _ Title C i 1—
(over)
DOH-1555(02/2004)