Rozell, Richard Lewis - _ rLF
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NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard Lewis Rozell "« "-- Male
Date of Death Age If Veteran of US.Armed Forces,
12/02/2023 94 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
UJ
p Manner of Death ❑X Natural Cause Accident Homicide OSuicide Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
C Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
,Town orVillage Cie 5601 568
Burial Date Cemetery,Crematory,or Facility Name
12/06/2023 Pine View Crematory
Entombment Address
MCremation Queensbury Town,New York
Donation
0�Removal Date Place Removed
and/or and/or Held
F Hold Address
N
0
4. Date Point of
N ETransportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2023 Registrar of Vital Statistics Megan Wolin(Electronically Signed)
(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:
I—
WDate of Disposition IL 101T 3 Place of Disposition rTr td�F,a 1' `
2 (address)
W
NCC (section) (tot numbe (grave number)
gName of Sexton or Person in Charge of P7i s '• L' di
z I(please print)
W Signature Title env
DOH-1555(07/18)p t of 2
I —'s7i
Public Health Law Sec. 4145(2b)
Receipt
-;si91 1,,
Human remains of delivered on 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# . -