Symonds, Rockwood Elmer I IQ- # 393
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rockwood Elmer Symonds Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/11/2023 52 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
W
pUJ []Manner of Death Natural Cause []Accident piHomicide []Suicide []Undetermined ❑Pending
I I 'Circumstances Investigation
W Medical Certifier Name Title
CI Jozef Oweis
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 0902
[ ]Burial Date Cemetery,Crematory or Facility Name
04/14/2023 Pine View Crematorium
[]Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
CL Date Point of
Cl)[]Transportation
p , by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
r Date Cemetery Address
1 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
5 Address
Q
W
LL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/14/2023 Registrar of Vital Statistics Danielle S Gillespie(Electronically Signed)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H �r/ �I ��t' C
Z Date of Disposition 1/-15-2013Place of Disposition %N� V r e..-1 /-..14
ILI2 (address)
W
Cl)
CC (section) ,! , ,/�-(loot numb / (grave number)
0 'Name of Sexton or Person in Charge Prem es �r'7 "'" y
(please print)
W Signature Title
DOH-1555(07/18)p id 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of t A ' delivered on ' , 20�
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#