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Emlaw, Jean 4 . ' # Igo NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Aye Jean Emlaw Female Date of Death Age If Veteran of U.S. Armed Forces, 11/28/2017 92 Years War or Dates Place of Death Hospital, Institution or riii City, Town or Village Queensbury Town Street Address Westmount Health Facility Manner of Death©Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined Pending q,- Circumstances Investigation Medical Certifier Name Title Roslyn Socolof MD Address , 42 Gurney Ln,Queensbury Town,New York 12804 '. Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 151 Date Cemeteryor Crematory ���[]Burial 11/29/2017 Pine View Crematorium 'it-❑Entombment Address gC1-emation Queensbury Hamlet, New York A Date Place Removed 1❑Removal and/or Held and/or Address 1 Hold rI Date Point of /ice LITransportation Shipment by Common Destination Carrier Date Cemetery Address i o-Q Disinterment 44,Mkt❑Reinterment Date Cemetery Address I Permit Issued to Registration Number 4 Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address '; 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom _° Remains are,Shipped, if()thee than Abave Address Tri Permission is hereby granted to dispose of the human remains described above as indicated. fma:s k Date Issued 11/28/2017 Registrar of Vital Statistics Caro ne7fBarber EtectronicaffySigned ; (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I 1/3t h7 Place of Disposition (),Nt�..,i idfir.C+l"moo i.'i (address) (section) /►lot number) r,, (grave number) Name of Sexton or Person in Charge of remises (pi se print) rIll Signature11 Title laitribIL. (over) DOH-1555 (02/2004)