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Pond, Jody NEW YORK STATE DEPARTMENT OF HEALTH ' // 7 CD Vital Records Section Burial - Transit vermit Name First Middle Last Sex Jody Lynn Pond Female Date of Death Age L If Veteran of U.S. Armed Forces, December 17, 2016 ' War or Dates i=_ Place of Deat Hospital, Institution or City,Town Villa Fort Edward Street Address 3 Washington Street W3 Manner of Death a Natural Cause III Accident ❑ Homicide ❑ Suicide El Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title „ . CI Michael Fuller, M.D Address 100 Park Street Glens Falls, NY 12801 Death Certifi ' d District Number Register Nu ber City, Town Village , d v, :r- Le u �r1 . 54 y /� ❑Burial Date Cemetery or Crematory December 19, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address ,. Hold I-0' Date Point of riv❑Transportation Shipment by Common Destination CI Carrier ❑ Disinterment Date Cemetery Address ElReinterment Date Cemetery Address Permit Issued to Registration Number ▪ Name&Funeral Home Carleton Funeral Home, Inc. ' 00281 _;:1 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above -rn Address Permission is here y g nted to dispose of the human ins described above as in ' ated. Date Issued/ /ln Registrar of Vital Statisti signature) District Numbena(� Place a C _...-doC_.c I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: -z3 1. ;' Date of Disposition 12/14/2016 Place of Disposition Quaker Road Queensbury,NY 12804 P/3►eU :tLr2-m v� ,W, (address) i (section) i /^ (lot number) (grave number) cf Name of Sexto r rs in Charge of Premises J 1- i G�✓i [ ;G.✓n 6-C.%Lf (please print) ,Cll. Signature Title e'/-2.- r!.ato (over) DOH-1555 (02/2004)