Davis,Jackson NEW YORK STATE DEPARTMENT , Q'F-)
OFHEALTH •••
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Last Sex
Jackson Davis
Date of Death Male
Age If Veteran of U.S.Armed Forces,
08/03/2022 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Granville Town
W Street Address Slate Valley Center for Rehabilitation and Nursing
Q Manner of Death nNahrral Cause nAccident nHomicide nSuicide nUndetermined nPending
W II II II II
U Circumstances Investigation
W Medical Certifier Name
Title
Joshua Starteri NP
Address
10421 State Route 40,Granville Town, New York 12832
Death Certificate Filed Town Of Granville District Number
City,Town or Village 5756 Register Number
52
Burial Date Cemetery,Crematory or Facility Name
ri08/08/2022 Pine View Crematory
Entombment
Address
Cremation Queensbury Town,New York
Donation
[]Removal Date Place Removed
H and/or and/or Held
( Hold Address
O
a Date Point of
U_) Transportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
nDisinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/08/2022 Registrar of Vital Statistics Jenny Linda i1'/f/artel(e(Electronically Signed)
(signature)
District Number 5756 Place Town Of Granville
,z,i,iy that the remains of the decedent identified above were disposed of in accordance with this permit on: /�
Place of Disposition " L '^�14� ` �.l�el(1---
Z
Date of Disposition 1 MA_ p`
(address)
a
(section) ,9 (lot numbed (grave number)
O Name of Sexton or Person in Charge of Premises (pie se print) /�
Title l 'rn
W Signature
DOH-1555(07/18)P 1 of 2
3 4
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#