Barrett, Agnes fi
NEW YORK STATE DEPARTMENT OF HEALTH I I
Vital Records Section , Burial - Transit Permit
_
Name First Middle Last Sex
Agnes H. Barrett Female
Date of Death Age If Veteran of U.S.Armed Forces, NO
1. December 16, 2013 90 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 0 Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
W Circumstances Investigation
o Medical Certifier Name Title
W Eric Pillemer MD
0 Address
102 Park Street Glens Falls New York 12801
Death Certificate Filed District Number Register N_ujnber
City,Town or Village Dresden 5 -7 j 2 9
❑Burial Date December 19, 2013 Cemetery or Crematory
Pine View Crematory
❑Entombment Address
▪ ®Cremation 21 Quaker Road Queensbury New York 12803
Date Place Removed
0 0 Removal and/or Held
- and/or Address
I' Hold
Date Point of
0 0 Transportation Shipment
d by Common Destination
i Carrier
Date Cemetery Address
tiDisinterment
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
I— Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IX
W Address
0.
Permission is hereby granted to dispose of the human remains described ab ve as indicated.
Date Issued I(P./jai/3/3 Registrar of Vital Statistics ,,? (�1L, __ '
/ (signature)
District Number 55 75 2_ Place Whitehall,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
W Date of Disposition I`/'I'I-13 Place of Disposition eat tIQ r( nr+w
2 (address)
W
In
I (section) (lo,�humber) (grave number)
O Name of Sexton or Person in Charge of Premises %i,1 �� �e` `
2 (pleas
W dri
Signature Title C afsi lwt
_
(over)
DOH-1555 (02/2004)