Hicks, Jean Elizabeth IIIL
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jean Elizabeth Hicks Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/13/2020 82 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Chester Town Warren Street Address 2883 Schroon River Road,Chester Town Warren,New York 12817
pManner of Death Natural Cause ❑Accident Homicide ❑Suicide Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
C John Rugge MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Chestertown 5652 10
ElBurial Date Cemetery,Crematory or Facility Name
10/14/2020 Pine View Crematorium
ElEntombment Address
Cremation Queensbury.Town,New York
Donation
Removal Date Place Removed
- and/or and/or Held
- Hold Address
0
O. Date Point of
Cl) u Transportation Shipment
p by Common
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/14/2020 Registrar of Vital Statistics Minily Conway(ECectronicaffy Signed)
(signature)
District Number 5652 Place Chestertown, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
▪ Date of Disposition /01J5-1 to Place of Disposition 1l".
(address/
W
(section) /1(lot numbe (grave number)
8 Name of Sexton or Person in Charge of P miles Or,
Z (pllse print)
W Signature Title 61,441N.
DOH-1555(07/18)p 1 of 2
011 .
3
Public Health Law Sec. 4145(2b) 10
Receipt
,
•
Human remains of —� delivered on , 20
Pine View Cemetery Representing the funeral home named in burial permit
Official Funeral Directors Reg.or License# f