Palmer-Jackman, Elaine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elaine Marie Palmer-Jackman Female
Date of Death Age If veteran of U.S.Armed Forces,
August 6,2011 47 War or Dates
I— Place of Death Hospital, Institution or
Z City Town r Village Hampton, New York Street Address 117 Campbell Lane, Hampton, NY 12837
C Manner of Death ®Natural Cause E Accident El Homicide ESuicide El Undetermined ❑Pending
Z Circumstances Investigation
W u Medical Certifier Name Title
W Ruth Scribner/Dr. Max Crossman Coroner
CI Address
55 Beckett Road,Whitehall, NY 12887
Death Certificate Filed District Number Register Number
City Town,Village Hampton, New York 57 5 8 3
— CIBurial Date Cemetery or Crematory
Entombment 8-11-2011 Pine View Crematory
Address Quaker Road,Queensbury,Cremation New York 12804
Date Place Removed
O ❑Removal and/or Held
i= and/or Address
41 Hold
O Date Point of Shipment
CL
❑Transportation
O by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Durfee Funeral Home&Cremation Service 023-30078651
Address
P.O.Box 86,119 North Main Street Fair Haven,VT 05743
Name of Funeral Firm Making Disposition or to Whom
l= Remains are Shipped, If Other than Above
2 Address
W a sal
Permission is hereby granted to dispose of the human re escribed above indicated. >`, ..
Date Issued 8 Registrar of Vital Statistics S
I 11 '� -� (signature)
l Place l d L T o-c rr'.to (
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition 8-11-2011 Place of Disposition Pine View Crematory
LU 21 Quaker Road Queensbury, NY 12804
W (address)
C
0 Q (section) (lot nurytaer) (grave number)
p Name of Sexton or person in Charge ` f Premises a tkir r tAt4
/a (please print)
Ill Signature / , � Title CIS e A AT Vt.
H - 1555 (02/2004) (over)
Air