Tilley, Jean II # 313
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean C. Tilley Female
Date of Death Age If Veteran of U.S. Armed Forces,
05 / 12 / 2016 77 War or Dates N/A
Place of Death Hospital, Institution or
WCity, Town or Village Saratoga Springs, NY Street Address 211 Church Street
p Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 7 Pending
ttl Circumstances Investigation
j Medical Certifier Name Title
0 Joshua Zammer MD
Address
211 Church St, Saratoga Springs, NY 12866
Death Certificate Filed District Number , Register ber
ti City, Town or Village Saratoga Springs, NY 2't
Burial Date Cemete or Crematory
05 / 16 / 2016 Pine View Crematory
0::. Entombment Address
ft E.Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
"—land/or Removal and/or Held
Address
O.
Hold
Date Point of
❑Transportation Shipment
a by Common Destination
iiiiii Carrier
Disinterment Date Cemetery Address
;iN' Q Reinterment Date Cemetery Address
ft
s' Permit Issued to 1 Registration Number
iiiiiiiii Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
402 Maple Ave., Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Z.
It
Permission is her y g anted to dispose of the human rem s des ri d ab f as ndicate
>° Date Issued 5 l J(f Registrar of Vital Statistics
(signature)
District Number 4 501 Place Saratoga Springs, NY , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition G717 f/` Place of Disposition intik, ( -
(address)
111
tr (section) zA(lot number) (grave number)
4 Name of Sexton or Person in Charge of Premises L t•r 5� �
Z A (p se print) -
Signature ( /111-11 Title a .01/3(
(over)
DOH-1555 (02/2004)