Toben, George NEW YORK STATE DEPARTMENT OF HEALTH • 1fi b
Vital Records Section Burial - Transit r ermit
Name First Middle Last Sex
George H Toben Male
Date of Death Age If Veteran of U.S.Armed Forces,
F, December 7, 2016 79 War or Dates 1957-1959
2 Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address Indian River Rehabilitation and Health C
0 Manner of Death ®Natural Cause ❑Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Hawed Sisdigvi, M.D. Dr.
Q Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number►1
City,Town or Village Granville 3725 'T
❑Burial Date December 14, 2016 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
®Cremation 42 Quaker Road Queensbury New York 12803
2 Date Place Removed
0 n Removal and/or Held
and/or Address
Hold
VI Date Point of
0 Q Transportation Shipment
A by Common Destination
Carrier
Date Cemetery Address
ci Disinterment
[(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
X Remains are Shipped, If Other than Above
W Address
0
Permission is hereby granted to dispose of the human remains it, it. i,as indicated.
' - �,5Date Issued I�i3�j(p Registrar of V•�tal Statistics ►esi�
(signature)
District Number 512-5- Place Granville,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition /2/i�/ �7'1(p Place of Disposition e 0 le IA) C f
.-reinw k l-
2 (address)
ILL
0
0 (section) (lot number) (grave number)
O Name of Sexton or in Charge of Premises in-i, G.A e..r✓l Q
Z (ple print)
W 9
Signature Title C /'Q iyl 4--/e"--
(over)
DOH-1555 ( 004)