Davis, Adrian NEW YORK STATE DEPARTMENT OF HEALTH II
Vital Records Section Burial - Trcansit Permit
4
Name First Middle Last Sex
Adrian C. Davis Male
Date of Death Age If Veteran of U.S.Armed Forces,
F May 24, 2017 67 War or Dates Y7�� f'g�p�-YZ
2 Place of Death - -. - Hospital, Institution or
W City,Town,or Village Whitehall Street Address His home
0 Manner of Death Watural Cause 0 Accident 0 Homicide n Suicide ElUndetermined n Pending
W Circumstances Investigation
0 Medical Certifier Name Title
Dr. Michael Sikirica, M.D. Dr.
Address
58 Broad Street, Waterford, NY 12188
Death Certificate Filed District Number5.1 rp(�o Register Number
City,Town or Village Whitehall
❑Burial Date Cemetery or Crematory
May 30, 2017 Pineview Crematorium
n Entombment Address
❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
Li Disinterment
I� �(Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
W Address
a.
Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued 1/4510212/,gyp;"'i Registrar of Vital Statistics £
/Thaw
(signature)
District Number 590?$ Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W
Date of Disposition 05/30/2017 Place of Disposition Pineview Crematorium
W (address)
(section) „/(lot number) r (grave number)
a Name of Sexton or Person in Charge of P emises 4 4es a, J
W (pl ase print)
Signature Title
!fin
(over)
DOH-1555 (02/2004)