Jardina, Victoria NEW YORK STATE DEPARTMENT OF HEALTH t t I/ g 1C
Vital Records Section Burial - Transit Permit
i: ,„ Name First Middle Last Sex
Victoria Kathleen Jardina Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 15,2017 65 War or Dates
` Place of Death Hospital, Institution or
City, Town or Village Thurman Street Address 3920 Main Street
Manner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
'ill Circumstances Investigation
i Medical Certifier Name Title
Paul Bachman
I Address
T ' 3767 Main Street,HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
p City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
November 20,2017 Pine View Crematory
ill Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
Cl. Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to Registration Number
y , 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
til- —IL
' Permission is h reb granted to dispose of the human remains de criibbed above as indicated.
Date Issued //4o7 /-7 Registrar of Vital Statist'
(signature)
. District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition i11((I 9 Place of Disposition e J,,,,.f �.c 1�..
2 (address)
cotu
ce (section) /h(lot number (grave number)
p �Name of Sexton or Person in Charge of Premises 6<- 1,..,41-
Z (plelease print)
uJ Signature Title tli K14q1/44e-
(over)
DOH-1555 (02/2004)