Jefferis, Patricia IF hinik
NEW YORK STATE DEPARTMENT OF HEALTH,. .., _, y
Vital Records Section Burial - Transit Permit
.-
Name First Middle Last Sex
Patricia Sue Jefferis Female
ti .y Date of Death Age If Veteran of U.S. Armed Forces,
September 25, 2015 80 War or Dates
Place of Death Hospital, Institution or
i City, Town or Village Street Address The Pines
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Melissa Decker, Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District NumberF jot_ tt Register,JV� ber
City, Town or Village )t !-�
❑Burial Date Cemetery or,Crematory
September 28, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
tr-i Removal and/or Held
and/or Address
Hold
Date Point of
4❑Transportation Shipment
liby Common Destination
Carrier
. ❑ Disinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
Permit Issued to Registration Number
61. Name of Funeral Home M.B. Kilmer Funeral Home-SGF 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
IX-
Permission is hereby granted to dispose of the human remains described above as indicated.
e
Date Issued ' %2g-jt5 Registrar of Vital Statistics l�Q1._- ,iv .Q.
(signature)
District Number 560 i Place 6 (ejc cGv \ S DJ y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) 4 (lot number) (grave number)
Name of Sexton or Person in Charge of Premises L t,i L 3e «
(/ease print)
Signature Title li2fhel(.
(over)
DOH-1555 (02/2004)