Jackson, Ruth # Zoe
NEW YORK STATE DEPARTMENT OF HEALTH +�Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth F.M. Jackson Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 19,2012 88 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address The Pines At Glens Falls
W° Manner of Death X Natural Cause I j Accident 1 Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
G Dr.Bernardo Villajuan
Address
90 South Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 11-1
❑Burial Date Cemetery or Crematory
111
Entombment April 20,2012 Pine View Crematory
Address
®Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
c
O Date Point of
N Transportation Shipment
aby Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
GG
W
Permission is hereby granted to dispose of the human remains de ribed ab ye a 'cated.
Date Issued QL//Z 20/Z Registrar of Vital Statistics
(si ature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/�
W Date of Disposition 1I11,0 lit Place of Disposition .� C.,nn4tt..�,
2 (address)
co
O (section) (lot number) (grave number)
pName of Sexton or Person in Charge of remises Zhu/ 114r
'Z I (please print)
Signature Title CPi 16-1- k
(over)
DOH-1555 (02/2004)