Perkins Jr, James NEW YORK STATE DEPARTMENT OF HEALTH Si
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Jr. C Perkins Male
Date of Death Age If Veteran of U.S.Armed Forces,
F July 12, 2015 48 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Home
Q Manner of Death ❑ Natural Cause ❑ Accident ❑`Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
O Medical Certifier Name Title
W /1/ii4x CJ: =E.,55Yls L l� •tJ•
d Address / / _
C 77L ��1mf( / �G` (f ``L 7 5 /
Death Certificate Filed j District Number Register Number
City,Town or Village Whitehall 5/6 3
❑Burial Date Cemetery or Crematory
July 16, 2015 Pineview Crematorium
❑Entombment Address
❑X Cremation Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I' Hold
Date Point of
❑Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Renterment 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 7(it(2 1 1 J Registrar of Vital Statistics £ .
(signature)
District Number 5160'/p Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 07/16/2015 Place of Disposition Pineview Crematorium
2 (address)
W
N
(section) (lo number) (grave number)
O Name
/of Sexton or Person in Charge of Premises h�,i} 'Se ttAtit
(please rint)
.4Signature � Title f►aurrIT1�t
(over)
DOH-1555 (02/2004)