Jordan, Alta �' W 1161
NEW YORK STATE DEPARTMENT OF HEALTIR
Vital Records Section Burial Transit Permit
s Name First Middle Last Sex
igi Alta L. Jordan Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/28/2014 93 yrs. War or Dates no
Place Bath Hospital, Institution or
City Town r Village Argyle Street Address Washington Center
Lii
Manner of Death Natural Cause Ei Accident 0 Homicide Ei Suicide ri Undetermined ri Pending
Circumstances Investigation
Medical Certifier Nan}e Title
'Address
r ST; e11M 136 70 G-�,/
Death Certificate Filed District Number '� "Register Number
City own r Village Argyle Sxv )`i
Date Cemetery or Crematory
❑Burial June 30, 2014 PineView Crematorium
Address
OCremation Queensbury, NY. 1 2804
Date Place Removed
0❑Removal and/or Held
r4- and/orHold Address -
0
2 Date Point of
y❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address .
[�Reinterment Date Cemetery Address
Permit Issued to R custr tion Number
aName of Funeral Home Mason Funeral Home oil 1
>` Address
18 George St. ,PO. Box 277, Ft. Ann, NY. 12827
... Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ffli Permission is hereby granted to dispose of the human remains described above as indicated.
i Date Issued 6/30/1 4 Registrar of Vital Statistics £ 7y4.411h,vw
(signat )
Iiiiii District Number 5.15 0 Place Town of Argyle, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ti
ill Date of Disposition 4/30/)y Place of Disposition 't+nap-) (. - ,r.
2 (address)
WI
0 CC g (section) dl9t numberk (grave number)
Name of Sexton or Person i Charge of Premises , ttiNy4-
F (please print)
Signature Title Cfl. (_
• (over)
DOH-1555 (9/98)