Estill, Shirley (14 t,..., 7, 502
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley A. Estill Female
Date of Death Age If Veteran of U.S. Armed Forces,
7/9/201 5 78 War or Dates no
j-; Place of Death Hospital, Institution or
W C (Town �rk�iII Wilton Street Address 202 Coop sr Dr.
Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined 0 Pending
VCircumstances Investigation
W Medical Certifier Name Title
4
Address
Death Certificate Filed District Number Register Number
Z/�City, Town or Village
Date Cemetery or,Cremators _
❑Burial 7/9/2015 Pine View Crematory
['Entombment Address
>EiCremation Queensbury, NY
Date Place Removed
Z ❑Removal and/or Held
2and/or Address
I= Hold
CO
O Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 CHurch St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2 Address
Jr
lit
3 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued �� �� Registrar of Vital Statistics �)/(
// (signatur
District Number Place `(Va\ 21
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
to Date of Disposition 1I511C Place of Disposition �;siAs �,-a' :—
', ► (address)
LU
til
CC (section) / (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises ` r Wrt
,�
2 (pl ase print)
W Signature L L Title ME"'Itrk
(over)
DOH-1555 (02/2004)