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George, Jessie -73 / NEW YORK STATE DEPARTMENT OF HALTH _ Vital Records Section Burial - Transit Permit ar Name First Middle Last Sex Jessie Ida George Female !S, Date of Death Age If Veteran of U.S.Armed Forces, 09/30/2017 95 Years War or Dates p4444 Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital W. Manner of Death©Natural Cause Ell Accident ❑Homicide ID Suicide ❑Undetermined ❑Pending Circumstances Investigation ui Medical Certifier Name Title 0 Julian Marynczak PA /444 Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number „flt, City, Town or Village Glens Falls 5601 513 ig ❑Burial Date Cemetery or Crematory 10/04/2017 Pine View Crematorium * El Entombment Address '4 '®Cremation Queensbury Town, New York ,, Date Place Removed Z Removal and/or Held 2I—i and/or Address Hold 0 Date Point of ❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address „' Date Cemetery Address t ❑Reinterment E: j Permit Issued to Registration Number 1 Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Stpo Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped, If Other than Above CO Address t Permission is hereby granted to dispose of the human remains described above as indicated. Al ji Date Issued 10/04/2017 Registrar of Vital Statistics gzp6ert A Curtis. Electronica1CySigned' (signature) MI1A 444-4 District Number Place 5601 Glens Falls, New York F= I certify that the remains of the decedent identified above were disposed of in accordance withit this permit on: W Date of Disposition �a-c/7 Place of Disposition �i�e.v ;-c(J t� C+:1�� (address) / C4 (section) (lot number), (grave number) aName of Sexton or e • Charge of Premises ild,./,. . vj 66 4G' (please print) W Signature s i'�(� Title 4r:° rnce (over) DOH-1555 (02/2004)