Jacobs, Eleanor f N # 9 O
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
,a
Name First Middle Last Sex
Eleanor Jacobs Female
, Date of Death Age If Veteran of U.S. Armed Forces,
November 18,2017 90 War or Dates NA
?: Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury,NY Street Address 94 Hudson Pointe Blvd.,Queensbury,NY
Manner of DeathLAil—`71Natural Cause ❑Accident ❑Homicide E Suicide ❑ d C
CircumstancesUnetermined Investigation
Medical Certifier Name A Title (�
Address
1. ( lalzGy QD C .k, of N7 1o9
' Death Certificate Filed District Number J 12 Register Number
City, Town or Village Queensbury,NY 5651 51 i �2�
❑Burial Date Cemetery or Crematory
❑Entomtxnent 11/20/2017 Pine View Crematory
Address
®Cremation Queensbury,NY
Date N Place Removed
ZO 1ri 1 Removal 1 and/or Held
and/or Address
H Hold
CO -
O Date Point of
v) Transportation Shipment
p by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd.,Queensbury,NY
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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 described above as indicated.
Date Issued l t-ati -ati ll Registrar of Vital Statistics —0.-04.1. .k2•��
(signature)
District Number ,51 Place 0 u - -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LI—
Date of Disposition /I/ain Place of Disposition ;,vV,,,r clC—.
W (address)
co
re (section) ,/(lot number)r (grave number)
pName of Sexton or Person in Charge of Pre ises (,(f„ ,.,,,cDi-
`Z /� (ple se print)
Signature G'� Title li4M1L
(over)
DOH-1555(02/2004)