Davis, Bonnie NEW YORKd STATE DEPARTMENT OF HEALTH, Burial - Transit• �r�mit
Vital Records Section
Name First Middle Last Sex
Bonnie J Davis Female
Date of Death Age If Veteran of U.S.Armed Forces,
F April 1 , 2011 62 War or Dates NO
Z Placety, of DeTown,
Town of Whitehall Hospital,rAInstitution or
Molinero Trailer Oark
W City,Town,or Village Street Address
0 Manner of Death ®Natural Cause El Accident ❑Homicide EISuicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Sean L. Kimball MD
a Address
79 North Street Granville New York 12832
Death Certificate Filed District Number Register Number
. ,City,l or Village te/ � �/ i'g i L f-7�7
❑Burial Date Cemetery or Crematory
April 4, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Town of Queensbury
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I" Hold
0 Date Point of
0 E Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
0 0 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00897
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
it
W Address
0.
Permission is hereby granted to dispose of the human remains describe abo as indicated.
Date Issued /j// Registrar of Vital Statistics
(sign re)
District Number 57Z� Place �=�' / �- -
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 9 -F I I Place of Disposition I 1 V t%„, `�ow*�¢
2 (address)
N
(section
)( ) ( . (Iot7 numb (grave number)
ZName of Sexton or Pe son in Charge o Premises h nsilidA i�►,rt}
W (please print)
Signature Title Cf2Elkitjpi2
(over)
DOH-1555 (02/2004)