Affinito, Gail NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Perm
Vital Records Section r
Name First Middle Last Sex
Gail M. Affinito Female
Date of Death Age If Veteran of U.S.Armed Forces,
f. January 18, 2018 79 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Home
0 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Andrew Garner MD
Q Address
8 Harrison Ai , Glens Falls NY 12801
Death Certificate Filed District Number Register Number '
City,Town or Village Whitehall 5`7 ag
❑Burial Date Cemetery or Crematory
January 22, 2018 Pineview Crematorium
❑Entombment Address
2 Q Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
a. and/or Address
Hold
0 Date Point of
4 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
U ❑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
et Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human rre�mains described above as indicated.
Date Issued 1/ /9)ao/' Registrar of Vital Statistics �.1, JA I, a- Y�'1,C,a
"` (signature)
District Number 57aS Place Whitehall,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 01/22/2018 Place of Disposition Pineview Crematorium
2 (address)
N
(section)) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises �,,w 4,
2 (phase prin
Signature / Title AVM 120.,
(over)
DOH-1555 (02/2004)