Peletier, Jennie lee NEW YORK STATE DEPARTMENT OF HEALTH �J
Bureau of Vital Records Burial - Transit Permit
Name First Middle
Last I Sex
Jennie Lee Pelletier
Date of Death Female
Age If Veteran of U.S.Armed Forces,
07/26/2022 76 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause Accident Homicide nSuicide Undetermined ❑Pending
W
C.) Circumstances Investigation
WW Medical Certifier Name Title
0
David Cunningham MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 394
Burial Date Cemetery,Crematory or Facility Name
® 07/28/2022 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
F_ and/or and/or Held
N Hold Address
0
O. Date Point of
N❑Transportation
aby Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Ill Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Other than Above
N Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/28/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1tySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 7-2%2oZL Place of Disposition rp,4e ai e-,-.J e rhl 440 r.S
W
(address)
W
N
CC
(section) (lot number) I (grave number)
elName of Sexton or Person in Charge Premises -----?A�/�f�O.J c7 (4)00 L"
Z (please print)
W Signature I�`� Title 0��
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) • `Y `"
Receipt
Human remains of , . •., ' - , delivered on 20
•
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#