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Williams, Beulah NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit 3 Permit Vital Records Section Name First Middle Last Sex Beulah M. Williams Female Date of Death Age If Veteran of U.S.Armed Forces, NO I. May 11, 2015 94 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 0 Natural Cause EI Accident ❑Homicide OSuicide 0 Undetermined ❑ Pending W Circumstances Investigation 0 Medical Certifier Name Title W Robert Beaty MD 0 Address 100 Broadstreet Glens Falls New York 12801 Death Certificate Filed District Number �^ 1 Register Number I� City,Town or Village Queensbury ,-�(SK-�r t7�.Jl 0 Burial Date Cemetery or Crematory May15, 2015 Pineview Crematorium ❑Entombment Address 0 Cremation Quaker Road Queensbury, NY 12804 Date Place Removed 0 0 Removal and/or Held - and/or Address Hold a 0 Date Point of 4 0 Transportation Shipment d by Common Destination Carrier Date Cemetery Address aLi 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 IX W Address 0. Permission is hereby ranted to dispose of the human remains des r bed above a icated. hil Date Issued ©S iy ZO/-� Registrar of Vital Statistics e,1y��/ L ` C ' s (signature) District Number 5lv0/ Place Q ee `iary-ruew York F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 W Date of Disposition 5 t'( / i Place of Disposition Pineview Crematorium 2 (address) W 0 iC (section) nu ber) / (grave number) Name of Sexton or rr Charge/of Premises CAL please'print) W Signature Title C,ViArinitl (over) DOH-1 5 (02/2004)