Woods, Jacqueline 1' - _ I 333
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section 1 Burial - Transit Permit
i,i,r Name First Middle Last Sex
Jacqueline M. Woods Female
Date of Death Age If Veteran of U.S. Armed Forces,
= June 27,2012 83 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Natural Cause riAccident El Homicide ElSuicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Stephen Offord,MD
Address
Saratoga Springs,NY
Death Certificate Filed District Number SQ� Registe Number
< City, Town or Village Saratoga Springs,NY n7
❑Burial Date Cemetery or Crematory
❑Entombment June 30,2012 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury, NY
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
W
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
El
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
. Address
53 Quaker Road, Queensbury,NY 12804
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 remai ri d ab`! -
o e as indicated.
(0,I Date Issued (A9xo/ca Registrar of Vital Statistics
/ (signature)
District Number �/ Place Saratoga Springs,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z RW Date of Disposition 1(1 ((2 Place of Disposition cW C orivy..
2 (address)
W
co
(section) - (lot number
p Name of Sexton or P son in Charg of Premises 4,,,$fi )c (grave number)
Z (please print)
W
Signature Title CiLfzem 1-p G1t
(over)
DOH-1555(02/2004)