Jackson, Blanche NEW YORK STATE DEPARTMENT OF HEALTH
VitallRecords Section Burial - Transit Permit
a
Name First Middle Last Sex
Blanche Luwella Jackson Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 18, 2011 74 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address The Pines
W Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Daniel C Larson M.D.,
Address
2 Broad St. Plaza Glens Falls, NY 12801
Death Certificate Filed Di . u rI Regi ec Jumber
City, Town or Village ..0
®Burial Date Cemetery or Crematory
September 22, 2011 Pine View Cemetery
❑Entombment Address
CI Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
E Hold Pine View Cemetery
Date Point of
❑Transportation Shipment
CD by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
W
O, Permission is hereby granted to dispose of the human remains described above,as indicated.
Date Issued 9/2-0//i Registrar of Vital Statistics (J..3 C �� W- -cl '
(signature)
District Number 560 i Place 6 5 \\5 IVY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 9/22/11 Place of Disposition Pine View Cemetery
(address)
W; Single Interment #2 29 2
( (section) (lot number) (grave number)
a Name of Sexton or Person 'nCharge of Premises Michael Genier
id
(please print)
W Signature 't'""'''�� TitleSuperintendent
CINA:JL44
(over)
DOH-1555 (02/2004)