Long, Joyace a" NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joyace Long Female
Date of Death Age If Veteran of U.S. Armed Forces,
Nov. 30, 2014 83 yrs, War or Dates no
— Place of Death Hospital, Institution or
ZCity, Town or Village Oueensbury Street Address 65 Dixon Rd.
a Manner of Death g Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ut Medical Certifier Name Title
'T, e 0 P 8/Ng m o.
Address
_MeV.614r . Ci RJG4i^/✓S' FigLLS Ny/-Pcpo/
Death Certificate Filed District Number Register Number
City, Town or Village Queens bury S(tS (Ste
opaq3Uflal Date Dec. 03, 2014 Cemetery or Crematory
PineView Cemetery
❑Entombment—Address
. ['Cremation Quaker Rd. , Oueensbury, NY. 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
CO
O Date Point of
liTransportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Mason Funeral Home Registration Number
Name of Funeral Home TT
Address
18 George St. , PO. Box 277, Ft. Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;; Address
t
to
P!'. Permission is hereby granted to dispose of the human r ins de= '• .. - soy as i icated.
1
Date Issued 1 2/01 /1 4 Registrar of Vital Statistics b._/ti,-A
(signature)
District Number (.4,S,1 Place Town of Oueensbury, NY.
I certify that the remains of the decedent identified abov were disposed of in accordance with this permit on:
nw
Date of Disposition (21 I+ Place of Disposition itUt)/i'eti) l.�t`Vt2. 2i 2/(/j,(,d�(.�l.th- I?..d e\(,(Pe/Aloor`t
(address)Ili
JJ
to Otihar)k. /29 A- 4
CC (s ction) (lot number) (grave number)
CI Name of S- .,•n or Person in Charge of Premises LoA)Aiir OCOE21
(please prin
Signatur: JV&' )., Tit
(over)
DOH-1555 (02/2004)