Norton, Theodore NEW YORK STATE DEPARTMENT OF HEALTH r l (�
Vital Records Section Burial - Ira
si Permit
Name First ^'' Middle `? Last Sex
Theodore B Norton Male
Date of Death I Age If Veteran of U.S.Armed Forces,
., August 4, 2014 P)C War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address His home
0 Manner of Death W Natural Cause ❑Accident ❑Homicide ESuicide ElUndetermined ❑ Pending
W Circumstances Investigation
Medical Certifier Name (j Title n
li
Address n� c)
t,e A:, 1 N ��
Death Certificate Filed District Number Register
Q ' umber ; �
City,Town or Village Granville G-7.5.(0 33 1
❑Burial Date Cemetery or Crematory
August 8, 2014
❑Entombment Address
Z El Cremation
Date Place Removed
4 ❑Removal and/or Held
- and/or Address
F Hold
0 Date Point of
0 0 Transportation Shipment
D.
by Common Destination
Carrier
Date Cemetery Address
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
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
a
Permission is hereby granted to dispose of the human remains descri above as indicated.
Date Issued $' 7 1 t Registrar of Vital Statistics
(signature
District Number SlsL 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 C W Date of Disposition 08/08/2014 Place of Disposition � aQ�
2 (address)
W
0
rr (section) lot numbe (grave number)
0 Name of Sexton or Person in Charge of Premises OQ,„ (4
W � (plt;ase print)
Signature //( ,11-- Title C7AVvire 1
(over)
DOH-1555 (02/2004)