Tackett, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH c 3
Vital Records Section Burial - Transit Permit
:; Name First Middle Last Sex
id Jeanne M. Tackett Female
ll Date of Death Age If Veteran of U.S. Armed Forces,
A June 30,2017 64 _War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 644 Corinth Rd.
Manner of DeathWkl Natural Cause Accident ❑Homicide Suicide I I Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Sikirica
v>,.s Address
€r 579 Grand Ave, Saratoga Springs, 12866
: De rt icate Filed District Number ister Number
°r: Cit , Town of Village (-k c8c.I
❑Burial Date Cemetery or Crematory
July 6, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
U
0 Date Point of
es ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
F Permit Issued to Registration Number
04 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 re1mains described above as.indicated.
Fa Date Issued 1, L'-(cc,') >Registrar of Vital Statistics G� fL�
f (signature)
91 -�' -
District Numbe���� �
Place
� �l d , C Cj ��
I certify that the remains of the decedent identified above were disposed of in accor nce with this permit on:
W Date of Disposition 1-1-11 Place of Disposition .inc iJ.,, Cr 4"-"I
W (address)
co
re (section) floc number) (grave number)
QName of Sexton or Person in Charge of Premises /L L.- hnitt
Z ease print)
W
Signature If Title (( l J 3nf 2
(over)
DOH-1555(02/2004)