Neptune, Jane q E .
fI 3 6/
NEWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fir Middl s Se
Jane �. kleptuneemale
Date of Death Age If Veteran of U.S. Armed Forces,
06/05/2014 B2 years War or Dates
1.- Place of Death Hospital, Institution or
ZX6 Town o 4 Horicon Street Address 48 Echo Mt. Road
• _Manner_of_Death.Q Natural-Cause Q Accident EIHomicide 0 Suicide ❑Undetermined . :Pending
iLi Circumstances Investigation
W Medical Certifier Name Title
C Glen Anderson RPA
Aci euarey Rd., Queensbur, Ny 12804
De h Certificate Filed District Number Register Number
X Town o ,MI Horicon _ 5654 3
Burial Date Cemetery or Crematory
06/09/2014 Pine View Crematorium
£Entombment
Address
;'Cremation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address ,
H Hold
CO
O Date Point of
LL
Transportation Shipment
O by Common Destination
.....Garner........_. .._ ..
Q Disinterment
Date Cemetery Address
"WAr
' Q Reinterment Date Cemetery Address
1...-:
Permit Issued to Registration Number
Name of Funeral Home Barton Mcdermott Funeral Home 00134
• Address..--
ne St, Chestertown, NY 12817
Name of Funeral„Firm Making:Disposition or to Whom _.,
1— Remains are Shipped, If Other than Above
• Address
cr
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/09/2014 Registrar of Vital Statistics caul
(signature)
District Number 5654 Place Horicon ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 0/jt/ Place of Disposition eua'✓ C�,.4#e,v,,,.
2 (address)
LEI
fa
LC (section) if (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises io't *Serer
► please print)
1.11
Signature Title C1r-ece i .
ti
(over)
DOH-1555 (02/2004)