Bay, Jeanine NEW YORK STATE DEPARTMENT OF HEALTH f 4 00
Vital Records Section Burial - Transit Permit
z Name First Middle Last Sex
Jeanine A. Bay Female
,E; Date of Death Age If Veteran of U.S. Armed Forces,
°g .} 03/14/2016 56 War or Dates
Place of Death Hospital, Institution o(39 .e/r '�
City, Town or Village Lake George Street Address -.Decea ed's Residence
Manner of Death 0 Natural Cause ❑ Accident 0 Homicide 0 Suicide iiUndetermined El Pending
Circumstances Investigation
Medical Certifie Ng�ij� h Titl
',--. /// , ,,'-K g V/ /0 7< q
Address / %i4
/� .,/j����o � CSGr/' r. � / fi
Deat ' 'cate File � j' /� _ District Num er Regist r Nu er
At Ci , Town o Village Lr' C-Ca eAc '/� '(pS—1
Date v
4,❑Burial or Crematory a ��
03/14/2016 �I�e�j .G%/-f'Cc ( 02-e.— -•F��1//s/yr1
ti5 Entombment Address
I ®Cremation 4,%-��jj�f� /lr Z��
,xb<� Date Place Remov d
Removal and/or Held
and/or Address
Hold
07 Date Point of
Transportation Shipment
4 by Common Destination
Carrier
1�t Date Cemetery Address
Disinterment
; Reinterment Date Cemetery Address
r
Permit Issued to Registration Number
'A Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
A Address
9 Pine St/P.O_ Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
i Permission is hereby granted to dispose of the human esnai s described abo as i dicated.
'° Date Issued 'j '-j ci (Co Registrar of Vital Statisti CC
(signature)
District Number 7 S I Place L ,4 L Q-t --Q
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition a I i5/Jt Place of Disposition irit if atertOcA .
(address)
Ig (section) A (lot number) (grave number)
'. Name of Sexton or Person in Charge of Premises a tii{UpLs-. Sc. i*
( lease print)
Signature a --; Title Signature
(over)
DOH-1555 (02/2004)