Morrison, Jeffry Dan NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last 1 Sex
73e.-r�Y'y ph,vx 1'A o cr► SonAA
"` / Age /G I If Veteran of U.S. Armed Forces,
I..,, Date of Death / /o� b I War or Dates N/mot/�
i. Place of Death Hospital, Institution or n^
5 City, Town or Village ukeeVl5L(Aril �� Street Address Mon--tan o , 5
Manner of Deathatural Cause 0 Accident 0 Homicide D Suicide El Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name --� Title
Q _) b A' 1 h De r fi S jft y Ci 4 0
Address 15 b/
a tk Cl.kv kolAd, Q(ACCV151, N L( 1 5e4
Death Certificate Filed /`-\ stf is— ber ister Number
City,Town or Village hAteE via try �J �
❑Burial I DateI /1-1/ .1.— Cemetery or Crematory I / / hy
271101
Address /�""
Cremation C2 via V[e_r- ??o,J
I Date Place Removed
0 II Removal and/or Held
and/or Address
g Hold
Date Point of
❑Transportation Shipment
in by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date ' Cemetery Address
Permit Issued to - Registration Number
Name of Funeral Home \�NC� ��,1 - -t \ HOcc
C i10
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
tr
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-' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued\\ )G11a04_[ Registrar of Vital Statistics KG_ C. V r,
(signature)
District Number Place sx, G C
f°
I certify that the remains of the decedent identified above were disposed of in accord. ith this permit on:
till Date of Disposition, -20-4a( Place of Disposition -P:aE Vd (rein*-/c
2 (address)
tla
to
EC (section) (lot number) (grave number)
0 Name of Sexton or Person in Char e Premises �P�f�lo•'A luio�
Z. ! (please print)
d •
Signature /-fi``' Title r"
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) `t 5 j 4
Receipt 01_
iHuman remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
Town of Queensbury
Certification of Cremation
� W Pine View Cemetery and Crematory
This certifies that the remains of: Jeffry Morrison
were cremated on February , 19 20 21 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death February , 17 20 21 Age 69
(Month) (Day)
Funeral Home Baker Funeral Home Registered No. 197
6 is-
(Authorized Signature)
y
MORRISON
NAME Jeffry Morrison Age: 69
Lot Owner: Ron & Danielle Gilligan
Lot# Mohican 60E Grave# 6
Case: Urn
Died: 2/1 7/2 0 21 Interred: 7/2 3/2 0 21
Funeral Home: Baker FH
Cemetery: Pine View