Perry, Ilene NEW YORK STATE DEPARTMENT OF HEALTH "'
Vital Records Section Burial - ra1GlSlt Permit
Name First ' Middle Last Sex
Ilene Perry Female
Date of Death Age 1 If Veteran of U.S.Armed Forces,
1. March 16, 2016 ‘7 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Sean Bain Dr.
a Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5�J� )y co
❑Burial Date Cemetery or Crematory
March 21, 2016 Pineview Crematorium
❑Entombment Address
ElCremation Quaker Road Queensbury, NY 12804
2 Date Place Removed
0 ❑Removal and/or Held
and/or Address
i" Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
1� n 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
tr Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby ranted to dispose of the human remains described a . dic
Date Issued 03 f 6 2o1b Registrar of Vital Statistics
(signature
District Number b 6'6i Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 03/21/2016 Place of Disposition Pineview Crematorium
2 (address)
W
0
0 (section) (lot number) (grave number)
4 /f
D Name of Sexton or Person in Charge of Premises C�h to Sir
W � ( ase print)
Signature :: Title "L
(over)
DOH-1555 '1412/2004)