Tyner, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH y•7U
Vital Records Section Burial - Transit Permit
t—., ,
Name First Middle Last Sex
ztt Jacqueline Ann Tyner Female
p Date of Death Age If Veteran of U.S. Armed Forces,
' x 6/2 4/1 5 51 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 73 Skara Brae Road
Manner of Death Et Natural Cause ❑ Accident E Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Craig Emblidge MDTitle
ii it. AddressSio Center, Glens Falls, NY 12801
A. Death Certificate Filed District Number Register Number
s City, Town or Village Lake George S6 5-j 5
❑Burial Date Cemetery or remato.
6/25/2015 Pine view crematory
❑Entombment Address
t
Cremation Queensbury, NY
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
.
Carrier
y ❑ Disinterment
Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 0 078
Address
Ft 136 Main St. So.Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human •' s descr' ed above as ' dicated.
Date Issued r° 4/) Registrar of Vital Statistics . "), 77a.4L q
47
T / (signature)
District Number 610 S/ Place ( aJe__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
: Date of Disposition '- S-i5 Place of Disposition (Pine if:ew Crew,,,4ar•'v01
(address)
(section n v r (lot number) (grave number)
;: Name of Sexton or Person in Charge of Premises i I.Yv►o`�-h l e &
-f r r �1' (please print)
Signature Title •1'� ►v,e I- r IQs 1{
(over)
DOH-1555 (02/2004)