Black, Linda 3 ilNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit vermit
Name First Middle Last Sex
Linda M. Black Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 02, 2017 77 yrs . War or Dates no
I— Place of Death Hospital, Institution or
W Cit , Town r Village Fort Ann Street Address 696 Goodman _Rd_
p Man of Death E.Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Peter Gray MD.
Address
Death . . ate FiledDistrict um r Registumber
City, own o illage Fort Ann 5754
['Burial Date Cemetery or Crematory
❑Entombment Mc�d� 0ess4, 201 7 PineView Crematorium
A
['Cremation Ouaker Rd_ , QncPnsbury, NY. 12804
Date Place Remove
Z n Removal and/or Held
Qand/or Address
t%) Hold
0 Date Point of
,% ❑Transportation Shipment
Cl by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
18 George St_ , 13..00 Box 277 Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
;g Address
1E
W
4' Permission is hereby granted to dispose of the human remains described as indicated.
/?i
Date Issued 5/0 3/201 7 Registrar of Vital Statistics ,(i/,‘,itia., i -
(signature)
District Number 5754 Place t/1, 77 / f j 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 514 In Place of Disposition 4301 — 6:rr ti;o,,,
W (address)
CO
CC (section) jr (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises !4r d' �' �,,+a 1 lr
•
z (pietase print)
Signature ,ja Title 7/4 Plf'! IC-
(over)
DOH-1555 (02/2004)