Morse, Jean NEW YORK STATE DEPARTMENT OF HEALTH # % Burial t,4 L'
Vital Records Section - ran it Permit
Name First Middle Last Sex
Jean M. Morse Female
Date of Death Age If Veteran of U.S.Armed Forces,
1., December 6, 2012 63 War or Dates NO
Z Place of Death Hospital, Institution or
W City,Town,or Village Whitehall Street Address Residence
G Manner of Death D Natural Cause ❑ Accident ❑Homicide El Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Eric Pillemer, M.D. Dr.
0 , Address
Glens Falls Hospital, Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Nurnberg
City,Town or Village Whitehall 51t*I L
❑Burial Date December 10, 2012 Cemetery or Crematory
Pine View Crematorium
❑Entombment Address
▪ 0 Cremation 42 Quaker Road Queensburyy New York
Date Place Removed
0 D Removal and/or Held
- and/or Address
Hold
0 Date Point of
n ❑Transportation Shipment
E. by Common Destination
Carrier
Date Cemetery Address
5 0 Disinterment
❑Renterment 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
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued l�f Cj fa01a l
- Registrar of Vital Statistics C44 Q 6 , P1-4_t^w1�
0 (signature)
District Number 7to 11/ Place Whitehall,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�^"'
w Date of Disposition (2-10^"(L Place of Disposition ��,t tJ Lrvre 0,..t�.
2 (address)
to
(section)( ) (lot number) (grave number)
ZName of Sexton or Person in Charge of Premises tit S-tot -
Z (pltlase print)
Signature /�r Title C w+t$oit
(over)
DOH-1555 (02/2004)