Jones, Patricia NEW YORK STATE DEPARTMENT OF HEALTH 4
f /5 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
▪ e, Patricia Ann Jones Female
▪ Date of Death Age If Veteran of U.S. Armed Forces,
February 21, 2017 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Albany Street Address Albany Medical Center
twID Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
t Medical Certifier Name Title
Nicholas Johnson, Dr.
Address
47 New Scotland Ave Albany, NY 12208
Death Certificate Filed G- oC \Yx'),,` District Numbe�� f Register Number
ber
City, Town or Village 1 a 9
'4,0 Burial Date Cemetery or Crematory
at February 23, 2017 Pine View Crematorium
• .;❑Entombment Address
;_LE Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Pine View Crematorium
Date Point of
❑Transportation Shipment
� by Common Destination
a Carrier
- ❑ Date Cemetery Address
Disinterment
❑ Reinterment Date Cemetery Address
All 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
z Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above
Address
,441
• Permission is hereby granted to dispose of the human re ins described abov as indicated.
• Date Issued 7'_ \ 7 Registrar of Vital Statistics �, s-N,, c 4
(sig ature)
District Number \cm\ Place e_ k-V:
41,4
- I certify that the remains of the decedent identified above a disposed of in accordance wi s permit on:
▪W Date of Disposition 02/23/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
Ili
(section) / (lot number) (grave number)
.
1�; Name of Sexton or Person in Charge of premises L hru J I",1 1�'
zr. (pl ase print)
WW Signature 1� Title let To l'akt
(over)
DOH-1555 (02/2004)