Willis, Nathaniel PERMIT MUST AC(SOMPANY REMAINS TO DESTINATION 5Z1
FORM BT-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO 6 2
BURIAL TRANSIT PERMIT 2.CITY OR TOWN 1640 t 040313OM
3.DECEDENT'S NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
NATHANIEL R WILLIS MALE SEPTEMBER 30,2012
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
28 Years AUGUST 17,1984 LEBANON GRAFTON
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation 5.Mausoleum 6.Other): CODE: 3
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINE VIEW CREMATORY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) OCTOBER 9,2012
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FINAL DISPOSITION(City/Town,State)
A CERTIFICATE OF DEATH,HAVING BEEN FILED AS REQUIRED BY THE LAWS OF THS STATE,PERMISSION IS HEREBY GIVEN TO:
16.FUNERAL DIRECTOR JAY T JILLSON 17.N.H.LIC.NUM ONLY 000
18.NAME AND LOCATION OF FACILITY(City/Town,State) JILLSON FUNERAL HOME,WHITEHALL,NY
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
JEFFREY S KNIGHT LEBANON OCTOBER 2,2012
CEMETERY OR STORAGE VAULT AUTHORITY SHALL FILL OUT SPACE BELOW WHEN APPLICABLE
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25.SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
(Month,Day,Year) (City/Town,State)
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30.SECTION 31.GRAVE NO. 32.SIGNATURE OF SEXTON OR PERSON IN CHARGE s(- '- 1
This permit,after being signed by the Sexton or person in charge(or by the Funeral Director ere there is no exton)must be forwarded within six days to
the clerk of the town in which the disposition takes place.