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Guarini, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit . Name First Middle Last Sex Jacqueline S. Guarini Female Date of Death Age If Veteran of U.S. Armed Forces, , . January 12,2017 54 War or Dates . Place of Death Hospital, Institution or r City, Town or Village Lake George Street Address 119 Mohican Street es:r Manner of Death n Natural Cause ❑Accident n Homicide n Suicide 1-1 Undetermined n Pending Circumstances Investigation Medical Certifier Name Title •/: Paul Bachmann,Coroner Address a 3767 Main Street Warrensburg,NY 7: Death Certificate Filed District Number Register Number <;. City, Town or Village Lake George ❑Burial Date Cemetery or Crematory El Entombment 01/18/2017 Pine View Crematory Address ©Cremation Queensbury, New York 12804 Date Place Removed Zn Removal and/or Held 0 and/or Address ... Hold CO O Date Point of Q. ❑Transportation Shipment a by Common Destination Carrier n Disinterment Date Cemetery Address n Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 , Address 53 uaker Road ueensbu 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 re ains described abo as indicated. Date Issued g I//EV zOI7 Registrar of Vital Statistics 01�2 r10. �; , (signature) District Number 563 Place Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z tDate of Disposition _ j f 1Q IA Place of Disposition `Pine,(jb✓ arn004% 2 (address) COIli p0 (section) ,j (lot number) (grave number) Name of Sexton or Person in Charge of Premises °/^li S,^4tlf- Z 147 (pase print) tL Signature Title (gE Mad (over) DOH-1555(02/2004)