Jacobs, Adelaide NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Adelaide M Jacobs Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/ 0/2011 Fife years War or Dates
Place o eat Hospital, Institution or
5 a) o Vy -z- Street Address
c� Glens Falls Park St Glens Falls. Ny 12801
o ,anner oYmtn a Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
`� Circumstances Investigation
ui Medical Certifier Name Title
II Mathew Varughese M D
Address
100 Park Street Glens Falls, Ny 12801
D h Certificate Filed District Number Register Number
ity TovkarxVilsticx Glens Fails cRn1 3n
urial Date Cemetery or Crematory
ii DEntombment 01/21/9011 Pineview Crematoryy
Address
099remation Q1;.^^nsbsrry, N Y 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
h= Hold
in
0 Date Point of
0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
tE! Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom •
Remains are Shipped, If Other than Above
2 Address
CC
ILI
` Permission is hereby granted to dispose of the human remains describbed abo/ as i cited.
Date Issued 01/21/201 1 Registrar of Vital Statistics 4‘111‘,vv ;-,
(signature)
District Number 5601 Place dens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ILI Date of Disposition Attu 6'1 Zeit Place of Disposition eftc O,¢w r s{a r,�...
2 (address)
in
0/}
CC (section) (lot number)C (grave number)
Ct Name of Sexton or Person in Charge 1 J ^^�/ Premises r 4 r�Sid �r 2 (f
2 (please print)
iLi. Signature /A7AL_i 4 Title C2EMt}TU
(over)
DOH-1555 (02/2004)