Jelliffe, James NEW YORK STATE DEPARTMENT OF HEALTF •,Vital Records Section Burial - Transit Permit
Name First Middle . Last Sex
James H Jelliffe Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. August 10, 2017 63 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Pittsfield Street Address 5247 Bluff Head Rd, Huletts Landing
G Manner of Death Ej Natural Cause 0 Accident ❑Homicide 0 Suicide El Undetermined D Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W William A.Tedesco MD
a Address
3 Irongate Center,Glens Falls, NY
Death Certificate Filed District Number Register Number
City,Town or Village Dresden 5 7 0 J
❑Burial Date Cemetery or Crematory
August 14, 2017 Pineview Crematorium
n Entombment Address
m, ❑X Cremation 21 Quaker Rd. ,Queensbury , NY 12804
Date Place Removed
0 n Removal and/or Held
m. and/or Address
I' Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
0 El Disinterment
ID
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 MakingDisposition or to Whom
� Po Crown Hill Funeral Home
1 Remains are Shipped, If Other than Above
d Address 700 West 38th Street, Indianapolis, IN 46208
Permission is hereby granted to dispose of the huma remains described above as indicated.p
Date Issued S�¢//7 Registrar of Vital Statistics
t^
(signature)
District Number 57E 1 Place / 1..//r/aM,f 1/1/. C/ed ^`
ern S !v y Jar/9
!- I certify that the remains of the decedent identified above were disposed ofin accordance with this permit on:
Z
W Date of Disposition 08/14/2017 Place of Disposition Pineview Crematory
2 (address)
Ui
N
(section
)) (lot number) (grave number)
O Name of Sexton or Person in Charge of Pr mises L f i r SiAq lit'
2 (p ase print)i Title (RSignatureVOW
(over)
DOH-1555 (02/2004)