Roaix Sr, Ora NEW YORK STATE DEPARTMENT OF HEALTH /I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ora Roaix Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
F November 18, 2014 75 War or Dates NO
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address 9863 State Route 4
G Manner of Death ® Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
Medical Certifier Name Title
W Max L. Grossman MD
Q Address
65 Poultney Street Whitehall New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 51 Le L
❑Burial Date Cemetery or Crematory
November 20, 2014 Pineview Crematorium
❑Entombment Address
0 Cremation Queensbury, NY 12804
Date Place Removed
0 ❑ Removal and/or Held
and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
ti by Common Destination
Carrier
= Date Cemetery Address
6 ❑Disinterment
El Reinterment 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
ii Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I I--c-o— f ii Registrar of Vital Statistics C: „(X.1:41.
11 (signature)
District Number 5 iv(p Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 11/20/2014 Place of Disposition Pineview Crematorium
2 (address)
40
(section) lot ber) / (grave number)
O Name of Sexton or •e •on harge of Pr mises je.t.) 6 1 G
/�� ( e se pry it)
Ill i
Signature ti / �� [ Title j ek ,r �Lki -
Nwl (
over)
DOH-1555 (02/2004)