Williams, Judy NEW YORK STATE DEPARTMENT OF HEALTH n
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Judy A Williams Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 9, 2015 (o5 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death 2 Natural Cause ❑ Accident ❑ Homicide ❑Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
U Medical Certifier Name Title
W
Address
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 135
❑ Burial Date Cemetery or Crematory
March 12, 2015 Pineview Crematorium
❑Entombment Address
ElCremation Quaker Road Queensbury, NY 12804
Date ( Place Removed
4 ❑ Removal , and/or Held
- and/or Address
Hold
Date Point of
0 ❑Transportation Shipment
No' Carrier
Common Destination
N Carrier
Date Cemetery Address
a ❑ 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
Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 31/ 1/3 Registrar of Vital Statistics (_v c Aty Vv
(signature)
District Number £V a ( Place Glens Falls,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 03/12/2015 Place of Disposition Pineview Crematorium
2 (address)
(section) ,,(lot number?... (grave number)
Z Name of Sexton or Person in Charge of Premises /4r. ir•ir-
( lease print)
Signature Title 614,
(over)
DOH-1555 (02/2004)