Loading...
Farnsworth, Jaime 5-IhNEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permi Name First Middle Last Sex Jamie G Farnsworth Female Date of Death Age If Veteran of U.S. Armed Forces, 11/13/2006 54 years War or Dates }: Place of Death Hospital, Institution or City, Town)�IKX tagtXXXX City Of Glens Falls Street AddressIli Glens Falls Hospital 0 Manner of Death To rtratural Cause 0 Accident 0 Homicide ElSuicide ri Undetermined ri❑Pending Lit Circumstances Investigation Medical Certifier Name Title 0 John Stoutenburq M D Address 102 Park Street Glens Falls, N Y 12801 Death Certificate Filed District Number Register Number a. City, Town XiMagXXXX City Of Glens Falls 5601 568 0Burial Date Cemetery or Crematory 11/16/2006 Pine View Crematorium [�ntombment Address ,Cremation Queensbury, NY 12804 Date Place Removed Z Removal and/or Held 9 ❑and/or Address F Cl) Hold Date Point of in Li Transportation Shipment C by Common Destination gi Carrier El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home, Inc. 00453 >; Address iiii 7 Sherman Ave. Corinth, NY 12822 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address #r l Permission is hereby granted to dispose of the huma emains described a love as in cat . iiiM Date Issued 11/14/2006 Registrar of Vital Statistics ` � -- (signatGre) Ei District Number _56©/ Place g iszAA5 V 1 i P y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ILI Date of Disposition it Al /tsb Place of Disposition ?tllvdr it Cre/rr+(tUr:urn—. 2 (address) 'Ai Cl) t= (section) (lot number) (grave number) Name of Sexton or Person in harge of Premises Cl r, snotd{- (please print) Signature Title Cam,, -r (over) DOH-1555 (02/2004)