Jump, Frank NEW YORK STATE DEPARTMENT OF HEALTH r +
s
Vital Records Section Burial - ranit Permit
- - Name First Middle Last Sex
Frank Oliff Jump Female
Date of Death Age If Veteran of U.S. Armed Forces,
kv
January 21, 2016 52 War or Dates
Place of Death Hospital, Institution or
ut City, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death Eli Natural Cause ❑ Accident El Homicide El Suicide ❑ Undetermined ❑ Pending
U`, Circumstances Investigation
Llts Medical Certifier Name Title
EEu
Noelle Stevens, M.D. Dr.
Address
100 Broad St. Glens Falls, NY 12801
Death Certificate Filed District Number Register)�Jujpber
City, Town or Village 5601 '�
- ❑Burial Date Cemetery or Crematory
January 25, 2016 Pine View Crematorium
Entombment
❑ Address
5 I Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
CO Date Point of
I ❑Transportation Shipment
G , by Common Destination
f' Carrier
s, ❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
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
- , Remains are Shipped, If Other than Above
Zi Address
-1:0i
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I 1 2 5 f/6 Registrar of Vital Statistics LA) C L-'i
(signature)
District Number 5601 Place G s \fix 1 is / ,
°` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I--
W; Date of Disposition 01/25/2016 Place of Disposition Quaker Road Queensbury,NY 12804
. (address)
L
3 (section) 4 (lot number)" (grave number)
Name of Sexton or Person in Charge of remises (Astir n J,4 MO
( lease print)
A Signature a i Title alhotfAi
(over)
DOH-1555 (02/2004)