Robertson, Janice NEW YORK STATE DEPARTMENT OF HEALTH" ' ' 11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
aii Janice M. Robertson Female
i.iii Date of Death Age If Veteran of U.S. Armed Forces,
)< April 01 , 2011 7-8= yrs. War or Dates no
14 Place of Death Hospital, Institution or
M City, Town or Village Glens Falls Street Address Glens Falls Hospital
Icy Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
fa Medical Certifier Namefthrkic Title
Address
il Death Certificate Filed District Number Regis er bi
_< � City, Town or Village Glens Falls 5601 ,
Date Cemetery or Crematory
❑Burial April 04, 2011 PineView Crematorium
�'']� Address
Cremation Town of Queensbury, NY.
Date Place Removed
0❑Removal and/or Held
n and/or Address
Hold
0 Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to Registration Number
;1 Name of Funeral Home Mason Funeral Home 0T1 36
Address
PO. Box 277, Fort Ann, NY. 12827
gi Name of Funeral Firm Making Disposition or to Whom
Lt Remains are Shipped, If Other than Above
Address
W AIM
4
Permission is hereby granted to dispose of the humanemains d cribed a ve as ind cated.
Date Issued 04/0 4/1 1 Registrar of Vital Statistics _47,2 � i pgj-tl___
(si na re)
ai
District Number 5601 Place City of Glens Fa s, NY.
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
I .
6 Date of Disposition II-Git Place of Disposition RA Ind Co"Kfot+v�
2 (address)
U.1
U)
CC (section) a ._ (lotnr tumber) (grave number)
0Name of Sexton or Person in Charg of Premises tisjor
g (please print)
Signature (?IiL. Title ceE pAr o(L.
(over)
DOH-1555 (9/98)