Rozell, Michael NEW YORK STATE DEPARTMENT OF HEALTH , , '� I
Vital Records Section Burial - Transit �b
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rmit
Name First Miadle Last Sex
Michael Rozell Male
Date of Death Age If Veteran of U.S.Armed Forces,
1, June 8, 2013 27 War or Dates no
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause 0 Accident 0 Homicide 0Suicide 0 Undetermined ® Pending
W aI� Circumstances Investigation
Medical Certifier P ul tsachman Title MD
W
Q Address
52 Haviland Ave Glens Falls New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls ..5-&Q I c._, y
CemeteryCremato
❑Burial Date June 14, 2013 or Pine View Crematory
❑Entombment Address
0 Cremation Town of Queensbury
2 Date Place Removed
0 0 Removal and/or Held
- and/or Address
f Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
: Carrier
V, Date Cemetery Address
o0 Disinterment
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
F= Name of Funeral Firm Making Disposition or to Whom
X Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human rerrta'ihs des ibed abote asjiin'ddicate .
Date Issued Q(D� /rOA3 Registrar of Vital Statistics „ �� 6(signature)
District Number Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
WDate of Disposition Ii'1( j Place of Disposition ,r kilsw Crwctd«v*c1
2 (address)
Li
to
te
0 (section) (lot number) c (grave number)
Name of Sexton or Person in Charge of Premises Li tom. • Ghrt
0
W (please print)
Signature 4--- /(1.--" Title CittEb►IIrTO1-
(over)
DOH-1555 (02/2004)