Degnan, Rodney NEW YORK STATE DEPARTMENT OF HEALTH e . A # Lilo
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rodney Michael Degnan Male
Date of Death Age If Veteran of U.S. Armed Forces,
Sept. 15, 2012 39 yrs. War or Dates no
Place of Death Hospital, Institution or
City, Town or Village So. Glens Falls Street Address Clear View Motel
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ®Pending
ill Circumstances Investigation
tu Medical Certifier Name Title
0 Michael Sikirica MD.
Address
50 Broad St. , Waterf c� NY.
Death Certificate Filed District Number Register Number
City, Town or Village So. Glens Falls 'i5ay / /
El Burial Date Cemetery or Crematory
Sept. 17, 2012 PineView Crematorium
li❑Entombment Address
iii x Cremation Town of Queensbury, NY. aid
Date Place R(lid
Z ❑Removal and/or Held
and/or Address
i= Hold
Date Point of
i0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Mason Funeral Home, 18 George St. Registration Number
»> Name of Funeral Home 01117
Address
Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tt
Permission is hereby granted to dispose of the human re in described o e as indicateee9
Date Issued 0 9/1 7/1 2 Registrar of Vital Statistics f1/C/l
(signature)
District Number 1-45-ag Place Village of So. Glens Falls, NY. 12803
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
IU Date of Disposition 1- 11-11, Place of Disposition 121...LL) C t ."
(addres t)
iti
CO
CC (section) 4.4 (lot bet) (grave number)
Name of Sexton or Person in Charg of Premises �'�} � °''
2 (please print)
ta
Signature _____4) Title C2+rm V0(t_
(over)
DOH-1555 (02/2004)