Mason, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section / `
iiiii Name First Middle Last Sex
Jeanne Phyllis Mason Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 3, 2015 "87 War or Dates
iPlace of Death �" Hospital, Institution or
City, Town or Village Glens Falls Street Address 18 Jefferson St.
es Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ttiCircumstances Investigation
Medical Certifier Name Title
William Tedesco MD
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
;:;;i City, Town or Village Glens Falls 5601 3 3 6
❑Burial Date Cemetery or Crematory
❑Entombment July 6, 2015 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i,R;:; Permit Issued to Registration Number
;i; :] Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
iiiiiii 53 Quaker Road, Queensbury, NY 12804
iiiiii Name of Funeral Firm Making Disposition or to Whom 1' Remains are Shipped, If Other than Above
Address
N.: Permission is hereby granted to dispose of the human remains described above as indicated.
if„
`ire° Date Issued 11 G / r 5 Registrar of Vital Statistics W 15-„e-st..W-1% '
iiiiii (signature)
` . District Number 5 6 Q I Place G ,S j 1\5 N v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition l/I,I i s Place of Disposition ?,,,Li �',,4.-f.,...
W (address)
co
Qcc (section) (lot number) (grave number)
Name of Sexton or Person in Charg of Premises /4.. �t„ -
Z (pl ase print)
W4 ,Signature Title /11-V irttl-
(over)
DOH-1555(02/2004)