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Whitehead, Jacqueline z5 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit §. Name First Middle Last Sex Jacqueline D. Whitehead Female >: Date of Death Age If Veteran of U.S. Armed Forces, March 25, 2017 90 War or Dates Place of Death Hospital, Institution or �> City, Town or Village So. Glens Falls Street Address Home Of The Good Shepard Manner of Death ❑X Natural Cause 0 Accident ❑Homicide Ti Suicide n Undetermined n Pending Circumstances Investigation rf• Medical Certifier Name Title Madison Zuis NP 41,5 Address 161 Carey Road,Queensbuty,NY 12804 r Death Certificate Filed District Number RegistpjNumber { City, Town or Village Moreau 4562 11I1 ❑Burial Date Cemetery or Crematory March 22, 2017 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road,Queensbury, NY 12804 Date Place Removed • n Removal and/or Held and/or Address H Hold Cl) O Date Point of yTransportation Shipment 5 by Common Destination Carrier n Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number ra Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Road, Queensbury,NY 12804 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 describedI .v as indicated. kg Date Issued 0 /J77ac.)/7 Registrar of Vital Statistics f ignatur District Number Place 3�1 / / / 4562 Moreau 6cfr,e7 (r S _ci, w,„:., ▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LUDate of Disposition ) Vila Place of Disposition ,,, J-✓ LwM2tot�ta-- W (address) CO re (section) (lot number) ( (grave number) OName of Sexton or Person in Charge of Premises f Ani � 3 t14aat- Z (pldase print) W Signature t7 Title CRAY104 (over) DOH-1555(02/2004)