Devlin, Jacqueline NEW YaRK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
7.' Name First Middle Last Sex
Jac r ueline
Devlin Female
o
Date of Death Age If Veteran of U.S. Armed Forces,
October 28 2014 81 War or Dates
Place of Death Hospital, Institution or
r- City, Town or Village Queensbury,NY Street Address 4 Sherwood Drive
hi
Manner of Death n Natural Cause ❑Accident n Homicide n Suicide Undetermined Pending
Circumstances Investigation
tri Medical Certifier Name Title
Patricia Auer,PA
Address
{ I ueensbu NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657 kid
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❑X Burial Date Cemetery or Crematory
❑Entombment November 1,2014 Pine View Cemetery
Address
❑Cremation Quaker Road,Queensbury, ,NY 12804
Date Place Removed
Z
❑Removal and/or Held
52 and/or Address
11' Hold
Cl)
O — Date Point of
O. _Transportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
' Permit Issued to Registration Number
Name of Funeral Home Sin.leton Sullivan Potter Funeral Home 01596
''
Address
407 Ba Road, II ueensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
ri Address
Permission is hereby granted to dispose of the hum. r :ins descr .^' • - as in>'cated.
air
Date Issued 1 C5_& -i L1 Registrar of Vital Statistic ► ,► ,�
(signa .re),-
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 11 /1 /2014 Pine View Cemetery
ui Date of Disposition Place of Disposition
(address)
N Huron 26C 3
re
(section) (lot number) (grave number)
Op Name of Se on or Person in Charge of Premises Connie L. Goedert
Z ( lease rint)
I" /ASuperintendent
Signatur seg-I.0 2 I`. decL€-.-( Title
(over)
DOH-1555(02/2004)