Gregory, Marion NEW YORK STATE DEPARTMENT OF HEALTH` Burial - Trains t Permit
Vital Records Section
Name First Middle Last Sex
Marion I Gregory Female
Date of Death Age If Veteran of U.S.Armed Forces,
E. November 21, 2015 89 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address The Orchard Nursing Centre, Inc.
0 Manner of Death El Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
O Medical Certifier Name Title
W Dr. Jennifer Hayes, M.D. Dr.
0 Address
17 Madison Street, Granville, NY 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 575(, 37
❑Burial Date Cemetery or Crematory
November ?,3, 2015 Pineview Crematorium
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
Z
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I" Hold
0 Date Point of
0 ❑Transportation Shipment
i by Common Destination
Carrier
Date Cemetery Address
6 ❑Disinterment
El 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
1-Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued i I i a 3 I t 5 Registrar of Vital Statistics t�v av
(signatu )
District Number s 75 6 Place Granville,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 11/25/2015 Place of Disposition Pineview Crematorium
2 (address)
W
Vi
0 (section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises (4 Sea t
W lease print)
.2Signature I. Title 47rL
(over)
DOH-1555 (02/2004)