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Rock, William Lee I'. Lr NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Lee Rock Male Date of Death Age If Veteran of U.S.Armed Forces, 08/05/2023 66 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address 15 Olive Street,Fort Edward Town,New York 12839 0 Manner of Death El Natural Cause Accident Homicide 0Suicide nUndetermined Pending W Circumstances Investigation U W Medical Certifier Name Title C Antonio Izzo NP Address 340A Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 69 Burial Date Cemetery,Crematory or Facility Name 08/07/2023 Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held ~ Hold Address W 0 Date Point of N rjTransportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address ElReinterment Date Cemetery Address 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 i- Remains are Shipped,If Other than Above 2 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/07/2023 Registrar of Vital Statistics Aimee G Makoney(ECectronically Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— , Z Date of Disposition $j S r z3 Place of Disposition ,7JJ 4 — (address) W N (section) fir (lot number) (grave number) �g Name of Sexton or Person in Charge of P mises �'-- et (p se print) al , Title fFFsvll Signaturear 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 91044 permit Official Funeral Directors Reg. or License#