Austin, Hanford NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Tranlit Permit
Name First Middle Last Sex
Hanford N. Austin Male
Date of Death Age If Veteran of U.S.Armed Forces,
F January 1, 2012 90 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address The Orchards
0 Manner of Death ❑X Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Sean L. Kimball MD
d Address
Granville Family Health, 79 North Street, Granville New York 12832
Death Certificate Filed District Number 1 sio Register Number
City,Town or Village Granville
-
❑Burial Date Cemeteryor Crematory
Jan. 4, 2012 Pineview Crematorium
❑Entombment Address
❑% Cremation Queensbury. NY Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
+� Carrier
r-I Date Cemetery Address
0 ❑Disinterment
El 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
it
0: Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j 13 I D 13. Registrar of Vital Statistics A. 6
NI ' nature)
District Number a%if) 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
W Date of Disposition I-5--11 Place of Disposition Pineview Crematorium
2 (address)
W
0
0 (section) (lot,number) (grave number)
0 Name of Sexton or Per n in Charge f Premises (I'
rsy'� r- -Debi,"
Z (p�e�ase print)
W
Signature Title CQ k oi qr;if
(over)
DOH-1555 (02/2004)