Abbott, William li
NEW YORK STATE DEPARTMENT OF HEALTI4 fill 7 t J,
Vital Records Section - ._ Burial - Transit Permit
Name First i' Middle Last Sex
William �, Abbott Male
Date of Death Age ' If Veteran of U.S.Armed Forces,
I. June 9, 2011 85 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address The Orchard Nursing Centre, Inc.
0 Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0Suicide El Undetermined El Pending
W Circumstances Investigation
0 Medical Certifier Name Title
Ill Nawed Siddieri MD
Q Address
10421 State Route 40, Ciranville, New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville .57510 a?
❑Burial Date Cemetery or Crematory
June 10, 2011 Pineview Crematorium
❑Entombment Address
I ❑x Cremation Queensbury, New York
Date Place Removed
4 0 Removal and/or Held
- and/or Address
1' Hold
0 Date Point of
0 E Transportation Shipment
O. by Common Destination
0 Carrier
- Date Cemetery Address
o ❑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
X
W Address
0.
Permission is hereby ranted to dispose of the human remains described abov� as indicated.
Date Issued bt 109�P0(t Registrar of Vital Statisticst?-",-vi
(signature)
District Number 5`-(5(o Place Granville,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition (6`t3-(4 Place of Disposition PthA 0 thw C c iwy,,,�
2 (address)
N
t
0 (section) (lo number) (grave number)
ZName of Sexton or Person in Charge of Premises 4fc,yt.C� LY. ii vIN i-
w dy_,
(please print)
Signature Title (h/) O _
(over)
DOH-1555 (02/2004)