Greene, Tina NEW YORK STATE DEPARTMENT OF HEALTH * Lb D
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tina M Greene FeMale
Date of Death Age If Veteran of U.S.Armed Forces,
1-, May 16, 2011 45 War or Dates no
Z Place of Death Village Whitehall Hospital, Institution or 1 20A Broadway
W City,Town,or Village Street Address
G Manner of Death 0 Natural Cause El Accident 0 Homicide EISuicide 0 Undetermined ci Pending
W Circumstances Investigation
() Medical Certifier Name Title
W Michael Sikirica MD
0 Address
50 Broad Street Waterford New York 12188
Death Certificate Filed Whitehall District Number Register Number
City,Town or Village 676 fo /A.
❑Burial D Ia y 25, 2011 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury New York 12803
Date Place Removed
0 0 Removal and/or Held
- and/or Address
I Hold
0 Date Point of
0 0 Transportation Shipment
D. by Common Destination
Carrier
= Date Cemetery Address
Disinterment
L� Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jilison Funeral Home, Inc. 00897
Address
46 Williams Street, Whitehall, New York 12887
I— Name of Funeral Firm Making Disposition or to Whom
X• Remains are Shipped, If Other than Above
W Address
is
Permission is hereby granted to dispose of the human re ins describe ab ve as indicated.
Date Issued 7-2 Y ( Registrar of Vital Statistics C
(si ture)
District Number74, Place /7. y
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
81 Date of Disposition S--ZS-tt Place of Disposition 49K411f�tiv C�� oio� _.
r ,
2 (address)
Z0 (section) _ (lo number (grave number)
Z Name of Sexton or Perso in Charge of remises t pa
(Tease print)
-*
Signature Title are_rwto(-
(over)
DOH-1555 (02/2004)