Jeror, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH 273
Vital Records Section - d„ Burial - Transit Permit
' Name First Middle Last Sex
Marjorie Wren Jeror Female
:__" Date of Death Age If Veteran of U.S. Armed Forces,
April 1,2017 85 War or Dates
Place of Death Hospital, Institutiordirondack Tri-County Health Care
• City, Town or Village Johnsburg Street Address Center
LU
O Manner of Death X Natural Cause I I Accident n Homicide Suicide Undetermined Pending
u.Im Circumstances Investigation
W Medical Certifier Name Title
e James Hindson Dr.
Address
Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Registp.,f Number
City, Town or Village Johnsburg 5655 '1
❑Burial Date Cemetery or Crematory
[1]Entombment April 3, 2017 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
0 Transportation Shipment
p by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
n.
Permission is hereby granted to dispose of the human r ins describe above a in 'cated.
' Date Issued 4-3-17 Registrar of Vital Statistics ea
(signatu
District Number 562,5e) Place T/O Johnsburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y/'i/ / fart Place of Disposition , ,.A/vv. �r�n`Cil0't',•,
2 (address)
W
CO
CL (section) �/ (jot number) ( (grave number)
Op Name of Sexton or Person in Charge of Premises r: J\N4ffit
Z (p ase print)
W
Signature 4 2 Title (1? fl
(over)
DOH-1555 (02/2004)