Tolman, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Jacqueline' Christine Tolman Female
F Date of Death Age If Veteran of U.S.Armed Forces,
November 7, 2013 57 War or Dates
Place of Death Hospital, Institution or
W' City, Town or Village Queensbury Street Address 5-Vincent Place
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
LJJ Circumstances Investigation
t
W: Medical Certifier Name Title
Mark Hoffman MD,
Address
420 Glen St. Glens Falls, NY 12801
Death Certificate Filed District Number Refer Dlumber
City, Town or Village 5657 Refit
14 4❑Burial Date Cemetery or Crematory
f November 12, 2013 Pine View Crematorium
3 ❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal
❑ and/or and/or Held
_ Hold
Address
Date Point of
at El TransportationShipment
by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
}-; Remains are Shipped, If Other than Above
2 Address
ti. Permission is hereby granted to dispose of the human r mains described po a as indicated.
- a Date Issued) ( ll . � .CZ�,
Registrar of Vital Statistics Q �'
-_-, ( (signature)
District Number 5657 Place I 0 --r1 C) Q\--02Q_-r-Ndc3, ,L
I certify that the remains of the decedent identified above were disposed of in
accordanc wit this permit on:
t Date of Disposition ti)1jc" Place of Disposition -`lncVctuJ6,,e{Griw
a (address)
W
07
(section) (lo umber) r (grave number)
• Name of Sexton or Person in C rge of Pr mises B""`
Z (please nnt)
W tl Ci� f+1 .
Signature Title
J (over)
DOH-1555 (02/2004)