Ashline, Sr. Wesley NEW YORK STATE DEPARTMENT OF HEALTH L'IL
Vital Records Section ,, 1 Burial - Transit Permit
Name First Middle Last Sex
Wesley A. Ashline, Sr. Male
Date of Death Age - If Veteran of U.S.Armed Forces,
I. August 27, 2011 82 War or Dates
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Residence - 117 Poultney, Street
G Manner of Death x❑Natural Cause ❑ Accident ❑Homicide El Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
Ill Mr. Max Crossman MD
Q Address
Whitehall Health Center, Poultney Street, Whitehall, New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 5764 /S
❑Burial Date Cemetery or Crematory
g/3//a0// Pineview Crematorium
❑Entombment Address
2 ❑Cremation Queensbury, New York
Date Place Removed
0 ❑Removal and/or Held
and/or Address
1' Hold
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
O ❑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
F= Name of Funeral Firm Making Disposition or to Whom
x• Remains are Shipped, If Other than Above
W Address
G.
Permission is hereby granted to dispose of the human remains describ d ove as indicated.
Date Issued ir%30,Z®// Registrar of Vital Statistics
gnature)
—
District Number .5-766 Place �C/� Gam—"`
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 15131 l/t Place of Disposition • L.L..) (,ivrcie to_
2 (address)
W
th
0 (section) /Li
ot num er) (grave number)
0 Name of Sexton or Person in Charge of Pre ises r .p,,,.{(}-
Z /14 (pleasprint)
W Signature Title CO i, M i B-
(over)
DOH-1555 (02/2004)