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Jones, Harriet NEW YORK STATE DEPARTMENT OF HEALTH , , 7,3g Vital Records Section • Burial - Transit Permit Name First Middle Last Sex Harriet May Jones Female Date of Death Age If Veteran of U.S. Armed Forces, March 25, 2016 86 War or Dates 1E Place of Death Hospital, Institution or W City, Town or Village Fort Edward Street Address 10 Bradley Street W Manner of Death mr1.i Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ri❑ Pending W, Circumstances Investigation ill, Medical Certifier Name Title Michael Adams MD, Address Moreau Family Health Ctr S. Glens Falls, NY Death Certificate Filed District Number Regiisger Number City, Town or Village 7oY1 ❑Burial Date Cemetery or Crematory March 28, 2016 Pine View Crematorium ❑Entombment Address +' ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ElRemoval and/or Held • and/or Address F. Hold Union Cemetery O Date Point of d ❑Transportation Shipment Cl) by Common Destination a Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 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 2 Address IX, W CL'° Permission is h reb granted to dispose of the human r described abov i dicated. Date Issued o .G ( Registrar of Vital Statistics 5 (signature District Number r(�� Place V (�CJ�` � ]/�U,_(1—(, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 03/28/2016 Place of Disposition Quaker Road Queensbury,NY 12804 2; (address) UI CO re (section) ` (lot number) (grave number) d Name of Sexton or Person in Charge of P emises 7!�I'i> Si'" Z,, /� � i(please print) �L� u Signature lid Title ` VIIIKOI, (over) DOH-1555 (02/2004)