Rehm Sr., Edward NEW YORK STATE DEPARTMENT OF HEALTI ' - 3 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward C. Rehm Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
F January 14, 2018 87 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Clemons Street Address Home
Manner of Death Natural Cause n Accident n Homicide nSuicide ❑Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
W
Address
Death Certificate Filed District Number Register Number
City,Town or Village Clemons
❑Burial Date Cemetery or Crematory
January 17, 2018 Pineview Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 ❑ Removal and/or Held
and/or Address
I" Hold
Date Point of
0 ❑Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
❑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
ir▪ Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ///7//S Registrar of Vital Statistics (im,l jr_e itharLtil
(signature)
District Number 515 2 Place Clemons,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 01/17/2018 Place of Disposition Pineview Crematorium
W (address)
In
(section
)( ) (lot number (grave number)
O Name of Sexton or Person in Charge of Premises (444, ,...417t
(please print)/�
Signature FA Q Title Arron'f/o,
(over)
DOH-1555 (02/2004)