Hill, Jacquelyn NEW YORK STATE DEPARTMENT OF HEALTH '` .. t GO
Vital Records Section \ Burial - Transit Permit
Name First Middle Last Sex
Jacquelyn O. Hill I Female
Date of Death Age If Veteran of U.S. Armed Forces,
• December 5, 2011 70 War or Dates
Place of Death Hospital, Institution or
:Z City, Town or Village Glens Falls Street Address 17 Lincoln Ave.
0= Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
u Medical Certifier Name Title
C3 Christopher Messitt MD
Address
135 North Rd,Wilton,NY 12831
Death Certificate Filed District Number R��u 0 mber
City, Town or Village Glens Falls,NY 5601
❑Burial Date j Cemetery or Crematory
— December 8, 2011 Pine View Crematory
— Entombment I Address
IN Cremation Quaker Road, Queensbury,NY 12804
' Date Place Removed Z
O Removal and/or Held
and/or
1- Hold Address
N
a.
a ' Date Point of N Shipment Transportation �
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Regan & Denny Funeral Home Registratio6ber
Name of Funeral Home
Yuaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i--: Remains are Shipped, If Other than Above
2 Address
us
Permission is hereby granted to dispose of the human remains
,cribed bo indicated.
/
Date Issued /z 07/2d!/ Registrar of Vital Statistics / ' JL
signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposedof in accordance with this permit on:
WDate of Disposition O,C 3�1 I Place of Disposition Pir..di c� Cu.-o�u(t s.._
(address)
W
to
re (section) / lot number)("' � (grave number)
QName of Sexton or Person in Char e of Premises �htt5t r— Jt hrtf'rl
W (please print)
Signature A4L, Title aFh_m}tdli.
(over)
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