Sabo, Mary NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle "I* Last Sex
Mary E Sabo Female
Date of Death Age If Veteran of U.S.Armed Forces,
j. September 13, 2016 --)3 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Clemons Street Address Home
G Manner of Death n Natural Cause ❑ Accident ❑Homicide n Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Glen Chapman, M.D. Dr.
Q Address
P. O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed District Number Register Num r
City,Town or Village Clemons 5 7 J 2 3 05
❑Burial Date Cemetery or Crematory
September 16, 2016 Pineview Crematorium
❑Entombment Address
al 0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 n Removal and/or Held
and/or Address
f' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Y TI Renterment 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
cc Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
p indicated.
Date Issued ( —/*-1 C' Registrar of Vital Statistics irvE (V.1 .' .--
(signature)
District Number 5 75 7 Place Clemons,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
� Date of Disposition 09/16/2016 Place of Disposition Pineview Crematorium
2 (address)
N
lt
section
� (section) A(lot number) (grave number)
Z
Person Premises b^n
Name of Sexton or in Charge of ` /- 3/.01'
W (please print)
41Signature 1 j Title ME:MA Mt'
(over)
')OH-1555 (02/2004)