Fernandes, Arthur •
NEW YORK STATE DEPARTMENT OF HEALTH- if IL 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur J. Fernandes Male
Date of Death Age If Veteran of U.S.Armed Forces,
F September 16, 2015 73 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address His home
0 Manner of Death X❑Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Tdle
W Dr. Max Crossman MD
0 Address
Whitehall Health Center, Poultney St. , Whitehall, New York 12887
Death Certificate Filed District Number'3 702 p p, Register Number w
City,Town or Village Whitehall
❑Burial Date Cemetery or Crematory
September 21, 2015 Pineview Crematorium
❑Entombment Address
0 Cremation Town of Queensbury Queensbury, NY 12804
2 Date Place Removed
0 Ej Removal and/or Held
- and/or Address
I" Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
Disinterment
Y 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
ir
Ir 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 q-1 g'0 %5 Registrar of Vital Statistics (: Qrywit..,-
4� )_ (signature)
District Number 5 lc g Place Whitehall,New,New York
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 09/21/2015 Place of Disposition Pineview Crematorium
2 (address)
00 (section) (lot number (grave number)
Name of Sexton or Person in Charge of Premises I J,t r,,,►�}
tll (pl ase print)
Signature -'-- Title fPPII)Q
(over)
DOH-1555 (02/2004)