Tyler, Willard NEW YORK STATE DEPARTMENT OF HEALTH Tt ca
Vital Records Section Burial - Transit Permit
Name First Midd)to Last Sex
Willard E. Tyler Male
Date of Death Age If Veteran of U.S.Armed Forces, '
F Febuary 1, 2014 64 War or Dates NO
Place of Death �L(., •
p �51-�le �o fie c _
z Hos �tal, Institution or
W City,Town,or Village 1a�.grd Street Address , Inc
0 Manner of Death 0 Natural Cause E Accident 0 Homicide QSuicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Maw Crossman MD
0 Address
65 Poultney Street Whitehall New York 12887
Death Certificate Filed District Number 57a Register Number '
City,Town or Village Whitehall
❑Burial Date Febuary 3, 2014 Cemetery or Crematory
Pine view Crematory
❑Entombment Address
0 Cremation Quaker Road Queensbury New York 12803
4 Date Place Removed
0 0 Removal and/or Held
- and/or Address
I- Hold
11) Date Point of
0 El Transportation Shipment
d by Common Destination
i Carrier
= Date Cemetery Address
0 0 Disinterment
Reinterment 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
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
CZ
W Address
a.
Permission is hereby ,,grantedr to dispose of the human r ains described above as indicated.
Date Issued c/3j /7 Registrar of Vital Statistics
+� �r (signature)
District Number 5 7 oC b Place Whitehall, New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition R1311y `'Place of Disposition ddres�fi41l�
W
th
ft (section) gist
number) (grave number)
0 Name of Sexton or Person in Ch4_arge of Premises r SW (pse print)
Signature Title cuing
(over)
DOH-1555 (02/2004)