Macy, Serenity NEW YORK STATE DEPARTMENT OF HEALTH ! 4/,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Serenity Macy
V".�r�cx
Date of Death Age If Veteran of U.S. Armed Forces,
01/17/2016 0 years War or Dates
1 Place of Death Hospital, Institution or
CityIli , TdtelfDC MUM Glens Falls Street Address Glens Falls Hospital
Manner of Death 11-1 Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ri❑Pending
6. 1- - \ '�.t,� , s-� Circumstances Investigation
tgi Medical Certifier Name Title
O Diana Suister M D
Address
45 Hudson Ave Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, TdW K&%Im X Glens Falls 5601 2
<>>❑Burial Date Cemetery or Crematory
01/22/2016 Pine View Crematorium
igii ❑Entombment Address
igil 'Cremation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address
t Hold
O Date Point of
Ili
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Ni Name of Funeral Home Jillson Funeral Home, Inc. 00885
Mi Address
46 Williams Street Whitehall, NY 12887
Ei Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above .
;'; Address
tr
ill
fl"` Permission is hereby granted to dispose of the human remains described above as indicated.
1
Date Issued 01/22/2016 Registrar of Vital Statistics k)Q�,,A¢ (/�/
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
7
• Date of Disposition I/1 h/f 1, Place of Disposition j Jii_i ( ,c;�otrs..i
2 (address)
ILI
CA
CC (section) (lot num er) (grave number)
0
0 Name of Sexton or Person in Char a of Premises r,o' 3r i/"
+ + (please print)
its Signature i/rf Title AraltIVI
(over)
DOH-1555 (02/2004)