Henry, Margaret NEW YORK STATE DEPARTMENT OF HEALTH ! Er, 1 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Margaret E. Henry Female
Date of Death A Age If Veteran of U.S.Armed Forces,
September 0, 2016 90 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 n Natural Cause 0 Accident D Homicide El Suicide ElUndetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Dr. Asim Chambry, M.D. Dr.
0 Address
Glens Falls, NY 12801
Death Certificate Filed District Number � Regis er yW`��nr
City,Town or Village Glens Falls i
❑Burial Date Cemetery or Crematory
September 8, 2016 Pineview Crematorium
❑Entombment Address
2 ❑X Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
4 0 Removal and/or Held
and/or Address
Hold
0 Date Point of
0 0 Transportation Shipment
L by Common Destination
Carrier
Date Cemetery Address
0 ❑Disinterment
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
2 Remains are Shipped, If Other than Above
X
W Address
O.
Permission is here ran
ted to dispose of the human mains d scribed above as indica
Date Issued �c (� /� Registrar of Vital Statistics g'_e. /721(
signature)
District Number ,-5---4.0 / Place Glens Falls,New Y rk
F I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
2
W Date of Disposition 09/08/2016 Place of Disposition Pineview Crematorium
2 (address)
lii
In
0 (section) y(Jot number) a (grave number)
O Name of Sexton or Person in Charge of Premises 8 iNiia`
W it
( lease print)
Signature L.Z 4 .t - Title T
(over)
DOH-1555 (02/2004)