Romeo, Jeanette ..,r„ "., �..,a. �a .» ,'••. av� �+ c, sin J17 JJO 1J11 IU:I.DlO l77JC1t= r.i'l
NEW YOFiK STATE DEPARTMENT OF HEALTH Burial - 1"ransit Permit
Vital Records Section
Name First — Middle Last s ,
Jeanette N. `� Romeo
. Date of Death Age If Veteran of U.S. Armed Forces,
_ War or pates
-. Place of Death Hospital, Institution or 141 Ringdahl Court
1N City, Town or Village Rome Street Address
p Manner of Death 0 Natural Cause Q Accident Homicide Suicide Undetermined ❑Pending
W _ Circumstances Investigation
W Medical Certifier . Name Title
O Kristen tandi MD
Address
100 Elizabeth Blackwell Street, Syracuse, New York 13210
Deatt, Certificate Filed - DistrictAtjber Register Number
. • City, Town or Village Rome
• ❑burial Date Cemetery or Crematory
11/24/2017 Fineview Crematorium
. []Entombment Address
•i a Cremation Queenbury, New York
I Date Place Removed
sZ O Removal and/or Held `
.H and/or Address
.� Hold
O Date -Point of
NQ Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
0
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
1—_Remains are Shipped, If Other than Above
2 Address
UP vr%
n` Permission is hereby granted to dispose of the hums . sins closer • ; - sbov 7fl Indies •.
Date issued 11/24/2017 Registrar of Vital Statistics , 9 \ , ` ' s'i sf •
f
(signature)
District Number 3201 Place Rome, Now •rk
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition II/14 I f Place of Disposition fi,ij...... n.c*i__._
2 (address)
uJ
al
0 (faction) (lot numb r) (gravy number)
c Name of Sexton or Person in Cbarge of Pre ises *sprint)
3 4.A.te
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Si nature Zt9 Title i �n wQ,
(over)
DOH-1555 (02/2004)