Manell, Gladys NEW YORK STATE DEPARTMENT OF HEALTH 3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gladys H Manell Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/17/2006 88 years War or Dates
Place of Death Hospital, Institution or
City, Town 90W1i4gCXXXX City Of Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident 0 Homicide D Suicide D Undetermined r 7 Pending
Circumstances Investigation
Medical Certifier Name Title
Patrick J Rowley M D
Address
80 South Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Town qi( 9XXXXX City Of Glens Falls 5601 228
[]Burial Date Cemetery or Crematory
05/22/2008 Pine View Crematorium
❑Entombment
Address
;\Cremation Queensbury, NY 12804
Date Place Removed
❑. El Removal and/or Held
: and/or Address
9 . Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00931
Address
46 Williams Street Whitehall, NY 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains describ d above a dica
Date Issued 05/18/2006 Registrar of Vital Statistics
(signature)
District Number 601 Place G G.. ik N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r
Date of Disposition c!a �!(;1. Place of Disposition t)m t ti'e ;,� rr � �-�
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 1,11N S ()ti.l rc b+
,
(please print)
Signature t-AA), .f sn. , Title t e t""",
(over)
DOH-1555 (02/2004)