Reyes, Sandra o C
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Trait I nsit Permit
•
Name First Middle Last Sex
Sandra Ly n e) Reyes Female
Date of Death Age If Veteran of U.S.Armed Forces,
F May 25, 2016 1 4 War or Dates
Z Place of Death Hospital, Institution or E
w City,Town,or Village Granville Street Address 1"
0 Manner of Death ''Natural Cause ❑ Accident ❑Homicide III Suicide n Undetermined 0 Pending
W Circumstances Investigation
Medical Certifier Name Title
W E. I e-e►n SF, 'I I Am_ R et el) 11,4j
3i-cis('q
Q Address
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Death Certificate Filed District Number Register Nuer
City,Town or Village Granville 514X5 ,WO
❑Burial Date Cemetery or Crematory
May 31, 2016 Pineview Crematorium
❑Entombment Address
Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 III Removal and/or Held
- and/or Address
I' Hold
J Date Point of
0 111 Transportation Shipment
on by Common Destination
Carrier
Date Cemetery Address
0 0 Disinterment
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
2 Remains are Shipped, If Other than Above
ft
W Address
a
Permission is hereby ranted to dispose of the human re ains-desc ' d a as indicated.
Date Issued / Registrar of Vital Statistics
signature)
District Number 5 5 Place Granville,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 05/31/2016 Place of Disposition Pineview Crematorium
2 (address)
Iil
It
0 (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises ahi Sin -
2 lease print)
Ill
Signature a Title azeh[�_
•
(over)
pOH-1555 (02/2004) �--