Crosier, Anna NEW YORK STATE DEPARTMENT OF HEALTH /
Vital Records Section 1,, a Burial - TransitFPermit
Name First Middle Last Sex
Anna M Crosier Female
Date of Death Age If Veteran of U.S.Armed Forces, A �
.. May 20, 2011 /S War or Dates /v O
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death gNatural Cause 0 Accident Homicide El Suicide n Undetermined D Pending
Circumstances Investigation
U Medical Certifier Name Title
Akk A � r is ,��/ coff ! �7
Death Certificate Filed District Number ! Register Number
City,Town or Village Glens Falls S 6 ! Z LI Z
❑Burial Date Cemetery or Crematory
May 24, 2011 Pineview Crematorium
0 Entombment Address
Q Cremation Queensbury Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
and/or Address
I- Hold
a
Date Point of
nn Transportation " Shipment
E. by Common Destination
Carrier
Date Cemetery Address
El 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
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indjcated.
Date Issued 51 Z.3 / 1 1 Registrar of Vital Statistics L,,L
(signature)
District Number .60 I Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fDate of Disposition 05/24/2011 Place of Disposition Pineview Crematorium
2 (address)
C0 (section) r- Uot number) (grave number)
Name of Sexton or Person in Charge f Premises 7+ +ts,f ��,t.c of
A (please print)
/71
Signature L Title Clionm6,
(over)
DOH-1555 (02/2004)