McLaughlin, Helene NEW YORK STATE DEPARTMENT OF HEALTH Z yy
Vital Records Section ` >� Burial - Transit Permit
Name First Middle Last Sex
Helene M. McLaughlin Female
Date of Death Age If Veteran of U.S.Armed Forces,
f, January 7, 2012 ig War or Dates
2 Place of Death Hospital,Institution or
W City,Town,or Village Granville Street Address Indian River Rehabilitation and
0 Manner of Death El Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
Medical Certifier Name Title
W Dr. Max Crossman MD
0 Address
Whitehall Health Center, Poultney St., Whitehall, New York 12887
Death Certificate Filed District Number Register Number
City,Town or Village Granville 51707 3"
0 Burial Date Cemetery or Crematory
January 11, 2012 Pineview Crematorium
D Entombment Address
®Cremation Quaker Road Queensbury, NY 12804
2 Date Place Removed
0 ❑Removal and/or Held
and/or Address
I' Hold
Li Date Point of
Q0 Transportation Shipment
d by Common Destination
g Carrier
Date Cemetery Address
o El
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
t= Name of Funeral Firm Making Disposition or to Whom
X Remains are Shipped,If Other than Above
W Address
a
Permission is hereby ranted to dispose of the human remain,,�descri abov indicated.
Date Issued j 09 ! Registrar of Vital Statistics � i _ -R
signatu
re)
)
District Number 5- Place Granvil le,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 01/11/2012 Place of Disposition Pineview Crematorium
2
2 (address)
g
0 (section) 7/ -. (lot number) c I. (grave number)
C Name of Sexton or Pe n in Charge remises (N r,yi-41 r t o,rrr
W (please print)
Signature tL . Title CI' tlA A-7,6iz
(over)
DOH-1555 (02/2004)