Austin, Jennie NEW YORK STATE DEPARTMENT OF HEALTH �` —
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jennie Mae Austin Female
' Date of Death Age If Veteran of U.S. Armed Forces,
I- May 4. 2006 91 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Kingsbury Street AddressResidence
Manner of Death Natural Cause 0 Accident Homicide Suicide El Undetermined 0 Pending
Circumstances Investigation
0 Medical Certifier Name Title
Suzanne Eppley
Address
340 Main Street, Hudson Falls, NY 12839
•
Death Certificate Filed District Number Register Number
City, Town or Village Kingsbury 5762 06
Date Cemetery or Crematory
❑Burial May 10. 2006 Pine View Crematorium
Address
0 Cremation Quaker Road Oueensburv, NY 12804-
Date Place Removed
0 0 Removal and/or Held
r and/or Address
Hold
Date Point of
Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
8El Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00284
Address
68 Main St., P. 0. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
0: Remains are Shipped, If Other than Above
WAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5-5-2006 Registrar of Vital Statistics (Q
signature)
District Number 5762 Place Kingsbury,New York
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition T j tt Place of Disposition Pin 1 c r..4;rt c
W (address)
to
If
(section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises ( k ro S.e n m
Z '� (please print)
/ /
Signature C Title