Storms, Helen NEW YORK STATE DEPARTMENT OF HEALTH] t Burial _ Transit Pel'rl'1 t�Z
Vital Records Section
Name First Middle Last Sex
Helen Storms Female
Date of Death Age If Veteran of U.S.Armed Forces,
November 6, 2017 91 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Moreau Street Address Home of the Good Shepherd-Moreau
o Manner of Death X❑Natural Cause Accident Homicide (Suicide n Undetermined n Pending
Circumstances Investigation
a Medical Certifier Name Title
W Dr. Robert Love, M.D. Dr.
Address
One Iron Gate, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau y56,2 S 9
❑Burial Date Cemetery or Crematory
November 8, 2017 Pineview Crematorium
❑Entombment Address
Q Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
n Removal and/or Held
ni and/or Address
Hold
Date Point of
0 111 Transportation Shipment
0. by Common Destination
Carrier
Date Cemetery Address
n Disinterment
Y 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
▪ 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 /0/ /7 Registrar of Vital Statistics '41 5
(signature)
District Number y5�(0 2 Place Moreau,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iDate of Disposition 11/08/2017 Place of Disposition Pineview Crematorium
2 (address)
N
(section)( ) „ (lot numbs (grave number)
O Name of Sexton or Person in Charge of Premises l�ril number-
W f (pease pnnt)
Signature �^ Title 44
(over)
DOH-1555 (02/2004)