Jorgensen, Linda NEW YORK STATE DEPARTMENT OF HgAtTH'
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Linda Jeanne Jorgensen Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 9, 2016 67 War or Dates n/a
Place of Death Hospital, Institution or
Z City, Town or Village Moreau Street Address 33 Iris Ave
O Manner of Death X Natural Cause I I Accident n Homicide In Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier—. Name{ Title
0 en ,4k),s-iy,
atldress Death Certificate File ' Y: D strict Number Register Number
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City, Town or Village Moreau, NY 4562
❑Burial Date Cemetery or Crematory
December 14 2016 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Ro_ad, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or •
Address
F" Hold
O Date Point of
(95 n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
U Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803 _
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
$ Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
r
Date Issued /01/6)/ Registrar of Vital Statistics A ir �# (�
(signature)
District Number L/-(o r, Place (J,.? erf , ?,4 Cc c�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition IL/I511,6 Place of Disposition €?OckLAJ i a,SN-.
W (address)
N
(section) /�/l (lot number) (grave number)
pName of Sexton or Person in Charge of Pr-mises 1 ^r'� t �8191
(ple se print)
Signature Title C�
(over)
DOH-1555(02/2004)