Golden, William NEW YORK STATE DEPARTMENT OF HEALTH 4 Zv
Vital Records Section 4 b Burial - Transit Permit
Name First Middle Last Sex
William R. Golden Male
Date of Death Age If Veteran of U.S.Armed Forces,
F May 4, 2012 83 War or Dates
2 Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Residence
G Manner of Death ❑Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W
Q Address
Death Certificate Filed District Number ' % Register Number
City,Town or Village Whitehall J1a-
❑Burial Date Cemetery or Crematory
Pineview Crematorium
0 Entombment Address
El Cremation Queensbury, New York Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I" Hold
-
0 Date Point of
0 ❑Transportation Shipment
d by Common Destination
Carrier
- Date Cemetery Address
5 ❑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
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
ft
W Address
0.
Permission is hereby granted to dispose of the human remains clescrib(gf�l above as indicated.
Date Issued -1_I a. Registrar of Vital Statistics (..JMAItAt
(signature)
District Number 5 1 al 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 5--- /2 Place of Disposition Pineview Crematorium
2 (address)
W
N
(section
)) (lot number) (grave number)
0• Name of Sexton or Person in Charge of Premises lam;r,,,, y u ne �C
Z (please print)
W
Signature Title Cfemet4,-kor7 I4 ,f
(over)
DOH-1555 (02/2004)