Jacobs, Muriel NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
% Name First Middle Last Sex
$ Muriel Jacobs Female
:j: Date of Death Age If Veteran of U.S. Armed Forces,
May 11,2015 94 War or Dates World War II
':ti Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death n Natural Cause n Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r
Eileen Spinelli MD
:::`� Address
i:::: 9 Carey Rd,Queensbury,NY 12804
•• Death Certificate Filed District Number Regist r umber
_titi3 City, Town or Village Fort Edward,NY 5755
❑Burial Date Cemetery or Crematory
May 12, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
(/)
0 Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
r. Name of Funeral Home Regan Denny Stafford Funeral Home 01443
;ti{: 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 reb granted to dispose of the hum- s dpscri.ed a as indicated.
Date Issued Registrar of Vital Statistics
(signature)
:f! District Number 5i 55 Place
Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of inn accordance with this permit on:
W Date of Disposition 5)iN1js- Place of Disposition -4 Cif
W (address)
Cl)
rY (section) opt number) (grave number)
pName of Sexton or Person in Charge of Premises 80, .J,r•atl-
Z (pleaSlb print
W
Signature Title tit1.0901
(over)
DOH-1555(02/2004)