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Simmons, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jeanne H Simmons Female Date of Death Age If Veteran of U.S.Armed Forces, F May 11, 2015 96 War or Dates z Place of Death Hospital, Institution or W City,Town,or Village Granville Street Address The Orchard Nursing Centre, Inc. G Manner of Death Q Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑ Undetermined ❑ Pending W Circumstances Investigation 0 Medical Certifier Name Title W Dr. Jennifer Hayes, M.D. Dr. Q Address 17 Madison Street, Granville, NY 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville 57 5 , 1 S. ❑X Burial Date Cemetery or Crematory May 15, 2015 St. Alphonsus Cemetery ❑Entombment Address ❑Cremation West Glens Falls, NY Date Place Removed 0 ❑Removal and/or Held and/or Address I' Hold 0 Date Point of 0 ❑Transportation Shipment Da by Common Destination Carrier Date Cemetery Address 0 ❑Disinterment ❑ Reinterment 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 ii W Address O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/1 4(2©IS Registrar of Vital Statistics 9 d )}'j ct, ,pfl, (signature) District Number 5'7 Place Granville,New York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition 05/15/2015 Place of Disposition St. Alphonsus Cemetery 2 (address) O AR- ► 3 3 0 (section) (lot number (grave number) • Name of Sexton o erson in Charge of Premises 'r e P("kA.. (_ Z (please print) Signature ��f Title / (� �� `f (over) DOH-1555 (02/2004)