Seeley, Jane •
NEW YORK STATE DEPARTMENT OF HEALTH i► . '. # I 510
Vital Records Section Burial Transit Permit
>' Name First Middle Last S x
Jane A. Seeley emale
e.
Date of Death Age If Veteran of U.S. Armed Forces,
March 06, 2014 74 yrs . War or Dates no
ZPlace of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 4 Gould Lane, Comstock
Manner of Death® Natural Cause Et Accident 0 Homicide Ei Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Luz Peguero MD.
iiiiiii Address
;' 2 "Broad St. Plaza, Glens Falls, NY. 12801
Death Certificate Filed District Number Registex Number
IN City, Town or Village Fort Ann 5754
Date Cemetery or Crematory
❑Burial March 10, 2014 PineView Crematorium
x Address
Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
fl and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
G by Common Destination
Carrier
: 11Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiii Permit Issued to Registrati9n.tlumber
Name of Funeral Home Mason Funeral Home
Address 18 George St. , Fort Ann, NY. 12827
'`< Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
114 Address
Cr
1k
Oi Permission is hereby granted to dispose of the human TT,i4s described above a -n ica d.
iliii Date Issued 0 3/0 7/1 4 Registrar of Vital Statistics �(4.; t o s .-� Zr
> ' (sign ,.el
ail r
iiil.iii District Number 5754 Place Town of Fort An , NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F 6 iii Date of Disposition 3lioliq Place of Disposition v yr
2 (address)
LU
Cl) (section) f Slot num er) (grave number)
Gz Name of Sexton or Person in Charge of Premises ^s w•6f
(please print)
t Signature Title CO Prt (
(over)
DOH-1555 (9/98)