Williams, Jeanette NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
j Vital Records Section
Name First Middle Last Sex
Jeanette A. Williams female
Date of Death Age If Veteran of U.S. Armed Forces,
06/11/2006 73 War or Dates n/a
Place of Death Hospital, Institution or
IQif(rQ , Town d X1XM( Queensbury Street Address Stanton Nsg. & Rehab. Ctr.
Ili
ci Manner of Death a Natural Cause Ei Accident Li Homicide 0 Suicide ri Undetermined Pending
U Circumstances Investigation
ta Medical Certifier Name Title
L Roslyn Socolof, MD
Address
152 Sherman Ave. , Queensbury, NY 12804
Death Certificate Filed District Number Register Number
XXV, Town =UK Queensbury 5657 1-0--
®Burial Date Cemetery or Crematory
06/14/2006 Pine View Cemetery,
<:: ,❑Entombment Address
❑Cremation Queensbury, NY
Date Place Removed
Z LI Removal and/or Held
and/or Address
r" Hold
0
0 Date Point of
i El Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny F1.tneral Home 01519
Address
53 Quaker Road, Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
ICE
U
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 t 3/0, Registrar of Vital Statistics`KC-- Q . C,3 ,'1,,,
(signature)
District Number S S'") Place c � J L.--r ,
I certify that the remains of the decedent identified above were disposed of in accordant it this permit on:
Z
iii Date of Disposition 6/14/06 Place of DispositionPlNF_ VIEW CEMETERY,QUEENS BU NY
(address)
IMt t ERIE 17-E 1
ilk (section) (lot number) (grave number)
Ca Name of Sexton or Person in Charge of Premises MI CHAFI BEN I FR
2 (please print)
I<tt •Signatur .>P � Title SUPT,
(over)
DOH-1555 (02/2004)