Jones, Florence NEW YORK STATE DEPARTMENT OF HEALTH # 56`]
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
:r: Florence P. Jones Female
Date of Death Age If Veteran of U.S. Armed Forces,
;: September 4, 2014 100 War or Dates
▪ Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
ilManner of Death X Natural Cause Accident Homicide I I Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Melissa Decker,MD
Address
9 Carey Road,Queensbury,NY 12804
y': Death Certificate Filed District Number Register Nuaer
:, ;: City, Town or Village Glens Falls,NY 5601 Lia
❑Burial Date Cemetery or Crematory
CI Entombment September 8, 2014 Pine View Crematory
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
Cl)
O Date Point of
yI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
: 53 Quaker Road, Queensbury,NY 12804
:g:: Name of Funeral Firm Making Disposition or to Whom
.� Remains are Shipped, If Other than Above
Address
ig
Permission is hereb rante to dispose of the hu an remain escribed .3ove as i dicated
9 P
:. . Date Issued CI Registrar of Vital Statistics _
signature)
''' District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
tu Date of Disposition 'i/ jg i Place of Disposition 4t1-. C- t ._
W (address)
CO
CX (section) (lot numbei' (grave number)
pName of Sexton or Person in Charge of Premises /1n.{ J,...,0
Z - I(please print)
W 440L Signature Title Oa WA
(over)
DOH-1555(02/2004)