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Hewitt, Jane U NEW YORK STATE DEPARTMENT OF HEALTF Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jane S. Hewitt Female Date of Death Age If Veteran of U.S.Armed Forces, I. April 9, 2015 78 War or Dates no 2 Place of Death Hospital, Institution or W City,Town,or Village Glens Falls Street Address Glens Falls Hospital o Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending W Circumstances Investigation 0 Medical Certifier Name Title W Dr. Marvin Daviswitz, M.D. Dr. 0 Address 100 Park Street, Glens Falls, NY 12801 Death Certificate Filed District Number�� Register Number City,Town or Village Glens Falls / ❑Burial Date Cemetery or Crematory April 14, 2015 Pine View Crematorium ❑Entombment Address ElCremation Quaker Road Queensbury New York 12803 Z Date 1 Place Removed 0 ❑ Removal and/or Held and/or Address i' Hold 0 Date Point of 0 ❑Transportation Shipment d by Common Destination i Carrier = Date Cemetery Address 6 ❑Disinterment ❑Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home, Inc. 00885 Address 46 Williams Street, Whitehall, New York 12887 ~ Name of Funeral Firm Making Disposition or to Whom X• Remains are Shipped, If Other than Above W Address 0. Permission is hereby granted to dispose of the human remains described above asrindicated. Date Issued 14 /1'112 ),j,Registrar of Vital Statistics W0...XA)p--v% W (signature) District Number S b© j Place Glens Falls,New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ,�^� W Date of Disposition 1/iCO Place of Disposition ,nc i„.4 cat-•. a.k.-- W (address) N 0 (section) ,,(lot number. (grave number) 0• Name of Sexton or Person in Charge of Premises A. r- 3/*toot Z � LI- Signature (plehse print) W G' Title c'Izbr►r}►v•L (over) DOH-1555 (02/2004)