Ashline, Eugene NEW YORK STATE DEPARTMENT OF HEALTH • ;' 41 9 ( 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eugene P Ashline Male
Date of Death Age If Veteran of U.S.Armed Forces,
1, August 11, 2012 77 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ®Natural Cause El Accident D Homicide 0Suicide ❑Undetermined n Pending
W Circumstances Investigation
U Medical Certifier Name Title
W C^/gvi L /<4n#1-G7 m / -
a Address
/Uo� P 4 scnc4_7 hs 1:::;97Zs A JP&u e /c /a7 Y' 1
Death Certificate Filed / District Number Register Number
City,Town or Village Glens Falls el 5 9
❑Burial Date Cemetery or Crematory
August 13, 2012 Pineview Crematorium
❑Entombment Address
n Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
l" Hold
0 Date Point of
0 0 Transportation Shipment
L by Common Destination
0Carrier
Date Cemetery Address
Q0 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
F— Name of Funeral Firm Making Disposition or to Whom
ix 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 g 11 3 I 1 2, Registrar of Vital Statistics LO �A., W
(signature)
District Number 560 I Place Glens Falls,New York
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 08/13/2012 Place of Disposition Pineview Crematorium
2 (address)
W
0
0 (section) (lo number) - (grave number)
0• Name of Sexton or Person in Charge of Pr mises (i)fi r J,j..r4f
Z pleaset)li .
W
Signature Title ale lrpiTO(L
(over)
DOH-1555 (02/2004)