Jones, Alice NEW YORK STATE DEPARTMENT OF HEALTH
It . y1 4 1oZ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice Shirley Jones Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/17/2012 86 yrs War or Dates no
.1 . Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death LLIcNatural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined El Pending
Circumstances Investigation
ill Medical Certifier Name Title
Ct Robert Beaty MD.
Address
Hudson Headwaters, Broad Si- _ , (;1 Pns Fatls, NY,
Death Certificate Filed District Number Register Number.-77
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
Feb. 21 , 2012 PineView Crematorium
❑Entombment Address
®Cremation Oueensbury, NY.
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
H Hold
t):
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
PO. Box 277, 18 George St. , Ft. ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
•
', Address
it
ILI
Permission is hereby granted to dispose of the human remains des i ed ov s i• • • - ed.
Date Issued 2/21 /1 2 Registrar of Vital Statistics
(signature)
District Number 5601 Place city of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tLI Date of Disposition Felo i f /ot L Place of Disposition 121,4 j(au Covtt()Cari
(address)
ILI
CA
CC (section) 4 - (lot number) r" (grave number)
et
Name of Sexton or P rson in Charge f Premises v r,A ^ "t".'tf-
..fir I (please print)
Signature Title C2 E AWtTOiL-
(over)
DOH-1555 (02/2004)