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Bolton, Mary Jane
i NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex —Mary Jane Bolton Female Date of Death Age If Veteran of US.Armed Forces, 01/07/2020 81 Years War or Dates E. Place of Death Hospital,Institution or City,Town or Village Horicon Town 7Street Address 491 Bean Road,Horicon Town,New York 12815 p Manner of Death ©Natural Cause Accident Homicide Suicide Undetermined Pending 12Uj Circumstances Investigation Medical Certifier Name Title Robert Love MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City.Town or Village Brant Lake 5654 2 Burial Date Cemetery,Crematory or Facility Name ❑ 01/08/2020 Pine View Crematorium Entombment Address Cremation Queensbury Hamlet,New York Donation ©Removal Date Place Removed and/or and/or Hold N Hold Address to ❑Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address 10 Reinterment Date Cemetery Address Permit Issued to Registration Number Naiht of Funeral Htittit Barton-Mcdemrott Funeral Home Inc 100141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom �•• Remains are Shipped,If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/08/2020 Registrar of Vital Statistics 7CristaGWWood(EfectronicalfySigned) /signatulel District Number 5654 Place Brant Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H 7 Z Date of Disposition 5 Zo Place of Disposition W 2 (address) W /sectfaiil AWnumwtl &ai4 is tidrl 0 Name of Sexton or Person in Charge of Premises (piw5eprintl W Signature Title DOH 1555(0748)p 1 of 2 Public Health Law Sec. 4145(2b) 0133220 Receipt Human remains of �.�. :;� �;� X Z �L/ delivered on , 20 �r Pine View Cemetery .Representing the funeral home named on burial-permit Official Funeral Directors Reg.or License#