Peterson, Agnes �RTMENT OF HEALTH .�+ 3�
j PCtiO .y_ �► vurial - Transit Permit
Agnes J. Peterson I Female I
I 1 Date of Death I Age I If Veteran of U.S.Armed Forces,
It"1 `':ay 10, 20 7 j IU( j War or Daies l
w IPlace of Death Hospital, Institution or
City,Town,or Village Granville Street Address Home
Manner of Death E Natural Cause El Accident El Homicide EISuicide ❑Undetermined D Pending
Circumstances Investigation
I(J Medical Certifier Name Title
W Dr. Max Crossman MD
8 Address
Whitehall Health Center, Poultney St. , Whitehall, New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5?54, 2g
❑Burial Date Cemetery or Crematory
May 12, 2017 Pineview Crematorium
❑Entombment Address
Z El Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
- and/or Address
1" Hold
0 Date Point of
4 n Transportation Shipment
L by Common Destination
Carrier
- Date Cemetery Address
6 ®Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jilison Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
G.
Permission is hereby granted to dispose of the human remains described above�J as indicated.
Date Issued O g I I A I ate(1 Registrar of Vital Statistics i a IPP.P
9 (signature
District Number S 7 S6 Place Granville,New York
F., I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
I Date of Disposition 05/12/2017 Place of Disposition Pineview Crematorium
(address)
W
0
0 (section) of number) (gravenumber)
0 Name of Sexton or Person in Charge of Premises lAn,s it ,,, r AA i It
Z (ple�se print)
W Signature l!:) Title 03E,*?2.
(over)
DOH-1555 (02/2004)