Martell, Daune NEW YORK STATE DEPARTMENT OF HEALTH a Burial - Transit rermit
Vital Records Section
Name First Middle Last Sex
Daune Ann Martell Female
Date of Death Age If Veteran of U.S.Armed Forces,
F June 1, 2017 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Fort Edward Street Address Fort Hudson Residential Health Care,
0 Manner of Death a Natural Cause 111 Accident n Homicide 0 Suicide 0 Undetermined n Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Nawed Siddiqui M.D. Dr.
0 Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward ,c75;' `7
1_,Burial Date Cemetery or Crematory
June 5, 2017 Pineview Crematorium
❑Entombment Address
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
0 El Transportation Shipment
D. by Common Destination
Carrier
Date Cemetery Address
13 0 Disinterment
n 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
F Name of Funeral Firm Making Disposition or to Whom
ce lY Remains are Shipped, If Other than Above
W Address
O.
Permission is h reby granted to dispose of the human r "ns described above as i icated.
Date Issued 6 / —D Registrar of Vital Statisti
( ignature)
District Number 5 7S Place Fort Edward,New York
H I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 06/05/2017 Place of Disposition Pineview Crematorium
2 (address)
W
0
0 (section) a
ot number) .(grave number)
0 Name of Sexton or Person in Charge of Premises tril (tr SiS Ott}
fU (please print)
4
Signature Title - [E Nat
(over)
DOH-1555 (02/2004)