Jefferis, Warren NEW YORK STATE DEPARTMENT OF HEALTH 5)0
Vital Records Section Burial - Transit Permit
Name First Middle . Last Sex
Warren D. Jefferis Male
-;71.24 Date of Death Age If Veteran of U.S. Armed Forces,
October 24, 2012 85 War or Dates
= Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation
`- Manner of Death El Natural Cause Accident El Homicide El Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address 152 Sherman Ave. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 6'`(DS'1 .37
Pi 0 Burial Date Cemetery or Crematory
October 26, 2012 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
a Carrier
0 Disinterment
Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
a Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
▪ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
' ,, Permission is hereby granted to dispose of the human emains escribe bov indicated.
▪ Date Issued r b. =)- a o/, Registrar of Vital Statistics_
(signature)
1
District Number s'---(0 5-7 Place � ,
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 10/26/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) li (lot number) (grave number)
w Name of Sexton or Per on in Charg of Premises Ar1ffiJ C"`�lt
1(please print)
Signature Title Crm-ra ,
(over)
DOH-1555 (02/2004)