Tyrell, Rita NEW YORK STATE DEPARTMENT OF HEALTH ' ` Burial - Transit Permit
Vital Records Section
Name First Middle Last ex
Rita J. Tyrell tn,Male
Date of Death Age If Veteran of U.S.Armed Forces,
F January 3, 2017 D War or Dates
2 Place of Death Hospital, Institution or
w City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death El Natural Cause IllAccident n Homicide D Suicide Ell Undetermined El Pending
W Circumstances Investigation
U Medical Certifier Name Title
111 Dr. Stephen Perazzelli, M.D. Dr.
0 Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number 1 Register Number C
City,Town or Village Glens Falls 5C60 I
❑Burial Date Cemetery or Crematory
January 6, 2017 Pine View Crematoy
❑Entombment Address
is Q Cremation Quaker Road Queensbury New York
Date Place Removed
0 n Removal and/or Held
- and/or Address
I Hold
0 Date Point of
0 n Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
Q ❑Disinterment
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
H Name of Funeral Firm Making Disposition or to Whom
fx it Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.r
Date Issued 1 / 5 , Ill Registrar of Vital Statistics 1ik
� CJ���(sig(signature)
V
District Number 5 G V 1 Place Glens Falls,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 01/06/2017 Place of Disposition I Inc°4" C rc ot—'
2 (address)
w
0
0 (section) lot number) (grave number)
0• Name of Sexton or Person in Charge of Premises r.c iavC/
W (ple se print)
Signature ,_ Title ItTh?L
(over)
DOH-1555 (02/2004)