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Daniels, Rocky L.
6 IS- NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rocky L.Daniels Male Date of Death Age If Veteran of U.S.Armed Forces, 01/22/2021 57 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Undetermined Pending W Manner of Death ©Natural Cause 1=1Accident 1=1Homicide 1=1Suicide U Circumstances Investigation LU Medical Certifier Name Title CI Abigail Macomber PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 44 EIBurial Date Cemetery,Crematory or Facility Name 01/23/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York ElDonation 0 Removal Date Place Removed and/or and/or Held N Hold Address 0 Q. Date Point of (I) ❑Transportation CI Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped,If Other than Above 2 Address CC W Q. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/22/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: +1 Z Date of Disposition I/2 S I Lt Place of Disposition - �,,,� W 2 (address) W N Q (section) (l umber) (grave number) 0 Name of Sexton or Person in Charge of Premiss /l t'' 1., ��^� Z (please pr t) �+ W G Signature i' ��--�i Title KY'"'�} 1 DOH-1555(07/18)p 1 of 2 { F Public Health Law Sec. 4145(2b) 0L 4 4.54 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#