Symonds, Rocky Jon Gf Lt
NEW YORK STATE DEPARTMENT OF H EALTH i Burial - Transit Permi
Bureau of Vital Records
Name First Middle Last Sex
Rocky Jon Symonds Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/01/2023 30 Years War or Dates
l— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 92 Warren Street 8, Glens Falls, New York 12801
p Manner of Death 0 Natural Cause EAccident Homicide Suicide Undetermined rid Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Michael Bell ME
Address — r--___
11650 NW 21st CT, Plantation,Florida 33323
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 15
Burial Date Cemetery,Crematory or Facility Name
01/10/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
n- Date Point of
Cl)❑Transportation
Q by Common Shipment
Carrier Destination
Ei
Disinterment
Date Cemetery Address
OReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1_— Remains are Shipped,If Other than Above
' Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/10/2023 Registrar of Vital Statistics Megan Nolin(ECectronicaCCySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I/i,IZ3 Place of Disposition '114L
/4______
2 (address)
W
CC (section) � (lot number) (grave number)
in Name of Sexton or Person in Charge ff' r ises ^ tt
0 /p`ase print)
Z
W Signature Title �t��110�7
DOH-1555(07/18)p 1 of 2
•
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
' Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#