Williams, Arlene NEW YORK STATE DEPARTMENT OF HEALTH r Y-1 Burial - Transit rmit
Vital Records Section
Name First Middle Last Sex
Arlene C. Williams Female
Date of Death Age If Veteran of U.S.Armed Forces,
I. April 26, 2016 84 War or Dates
Z Place of Death Hospital, Institution or
w City,Town,or Village Granville Street Address The Orchard Nursing Centre, Inc.
0 Manner of Death ❑Natural Cause ❑ Accident n Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Pamela Casey NP
0 Address
10421 State Route 40, Granville, NY 12832
Death Certificate Filed District Number 6 f75-` _ Register umber
City,Town or Village Granville 1 �k' `/
n Burial Date Cemetery or Crematory
April 29, 2016 Pineview Crematorium
❑Entombment Address
▪ Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address •
Hold
0 Date Point of
Q ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
n ❑Disinterment
L� ❑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
ix Remains are Shipped, If Other than Above
W Address
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y/o )/( Registrar of Vital Statistics c2,
75Lo Coast; of 11*ature)
District Number Place ranville,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 04/29/2016 Place of Disposition Pineview Crematorium
2 (address)
W
N
0 (section) (lot number) (grave number)
00 Name of Sexton or Person in Charge • Premises J
W d ( leaseprint)
Signature Title r! t
(over)
DOH-1555 (02/2004)