DeGroff, Winifred ''RK STATE DEPARTMENT OF HEALTI* ) •3 O
cords Section Burial - ransit Permit
dame First Middle Last Sex
Winifred H Degroff Female
Date of Death Age If Veteran of U.S.Armed Forces,
r
. June 10, 2012 79 War or Dates NO
Z Place of Death Hospital,Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0Suicide Undetermined 0 Pending
W Circumstances Investigation
Medical Certifier ___„ Name _____.--, Title
W A'oa G G`�cs 4- 81. 0
O 6 3 .are,-7 r � 7Te•e(- 6,6 ,-75 I—ress s it)-Et d yak_L f 2 )/
Death Certificate Filed / District Number Register Number._
City,Town or Village Glens Falls 5 66 ` 2-
❑Burial Date Cemetery or Crematory
June 12, 2012 Pine View Crmatorium
❑Entombment Address
®Cremation Town Of Queensbury
Date Place Removed
0 0 Removal and/or Held
- and/or Address
P Hold
-
0 Date Point of
0 D Transportation Shipment
o. by Common Destination
Carrier
Date Cemetery Address
0 El Disinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Hose, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
rere Remains are Shipped,If Other than Above
W Address
a.
Permission is hereby granted to dispose of the human remains described abov as ,, r ed.
Date Issued e,:'4s / ZC7 t G
Registrar of Vital Statistics. , =v
' (signature)
District Number SO( Place it- Cam=7� / A, /LY ( a 'i U i
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z tu �l Coil
W
Date of Disposition t, S lit Place of Disposition ?NV uv
(auuress)
N
z0 (section) (lo number) (grave number)
Name of Sexton or Person in Charge of remises (A f St r Sghr4('1-
W alek
(please pfint)
Signature Title CV11,1,_M A-Tvc.
(over)
DOH-1555 (02/2004)