Charpentier, Loretta NEW YORK STATE DEPARTMENT OF HEALTH * '`,IL .t ZZ:
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Loretta Charpentier Female
Date of Death Age If Veteran of U.S.Armed Forces,
I. April 28, 2011 92 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
0 Manner of Death x❑Natural Cause ❑ Accident ❑Homicide ❑Suicide E Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Max L. Crossman MD
0 Address
65 Poultney Street, Whitehall, New York 12887
Death Certificate Filed District Numb//,er Register Number%lei
City,Town or Village Whitehall `9 /0
El Burial Date Cemetery or Crematory
May 2, 2011 Pineview Crematorium
❑Entombment Address
Z 0 Cremation Queensbury, New York
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
C. by Common Destination
Carrier
Date Cemetery Address
O 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
I— Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is hereby granted to dispose of the human r ains described above as i icated.
Date Issued �7.2 9'—" Registrar of Vital Statistics
L , 0
r 7 (signature)
District Number/ lQ� Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
wDate of Disposition 6 /2 I I I Place of Disposition e.nQ U�.i t.�' Cniok<j v r 1u
2 (address)
N
0 (section) (lot n mber) S (grave number)
° 7.7/
At/rib,
Z Name of Sexton r Person in C rge of Premises r f,�.{�`}.
W f�1� (pl ase print) t
Signature ` 7 Title C Q F r y ; q
(over)
DOH-1555 (02/2004)