Terry, Gene NEW YORK STATE DEPARTMENT OF HEALTH b Vital Records Section s Burial - Transit Permit
Name First Middle Last Sex
Gene C Terry Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. May 9, 2016 80 War or Dates
Z Place of Death Hospital, Institution or
iii W _City,Town,or Village Whitehall Street Address Residence
CI Manner of Death n Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Mark Hoffman, M.D. Dr.
0 Address
420 Glen Street, Glens Falls, NY 12801
Death Certificate Filed District Number I� Register Number
City,Town or Village Whitehall 5'1 ix
.3
❑Burial Date Cemetery or Crematory
May 16, 2016 Pineview Crematorium
❑Entombment Address
❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 ❑Removal and/or Held
and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
o ❑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
~ Name of Funeral Firm Making Disposition or to Whom
x Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5-!l 2t. )6 Registrar of Vital Statistics c)r ' a .
(signature)
District Number d 7 Irk Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 05/16/2016 Place of Disposition Pineview Crematorium
2 (address)
W
9)
t
(section) �ht lio_t number)S (grave number)
W Name of Sexton or Person in Charge of Premises
Wease( print)
Signature Title akEpirtioE
(over)
DOH-1555 (02/2004)