Massa, Jillian 33
NEW YORK STATE DEPARTMENT OF HEALTH ; _x It
(1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jillian Colleen Massa F
Date of Death Age If Veteran of U.S. Armed Forces,
July 17 , 2006 27 War or Dates T?)
Place of Death Hospital, Institution or
Town of Moreau G?e s t River Road
2tt1 City, Town or Village Street Address C a n s e v o o r t , rTv , 2 2 T
p Manner of Death❑Natural Cause X❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
IW Circumstances Investigation
to Medical Certifier Name Title
GQ J. Paston 11. D.
Address
211 Church St . Saratoga. Springs , NY
Death Certificate Filed mom of MoreauDistrict Number _ Register Number
City, Town or Village y5w �` i S
El Burial Date Cemetery or Crematory
July 21 , 2006 Pine View Crematory
['Entombment Address
OCremation Quaker Road , Queensbury, NY 12604
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
(/)
Q Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
DDisinterment Date - Cemetery Address
n Reinterment Date Cemetery Address
—---- I j
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 0114.2
Address
82 Broadway Fort Edward , NY 12828
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Z Address
i=
W
°` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7120 l0(4, Registrar of Vital Statistics J�,iko ,1
! (signature)
District Number i57 9 Place Ai } i1n5cry J; `j iloYT/ 6U/o 1 /.-A„,.S r /.2a'o3
1F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition ?/4.,-f t✓r A Place of Disposition P ri l*",t C <7,n x1tc'r;v«-,
(address)
Li
CC (section) A (lot number) (grave number)
QName of Sexton j or Person in Charge of Premises 1l` 5 ��"'"'�
z ,. _ (please print)
ig Signature ( 'yam '`L"A'—, Title l- '�-�� 'C
(over)
DOH-1555 (02/2004)