Bullock, Jean NEW YORK STATE DEPARTMENT OF HEALTH 41 it Il
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jean Marie Bullock Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 26, 2013 81 War or Dates
1' Place of Death Hospital, Institution or
tu City, Town or Village Queensbury Street Address WESTMOUNT HEALTH CARE FACILITY
Manner of Death J Natural Cause Accident Homicide Suicide Ej Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Roslyn Socolof_MD,
Address
100 Broad St Plaza Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
-_ City, Town or Village `i 5'l 3)
❑Burial Date Cemetery or Crematory
March 29, 2013 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
z Li Removal and/or Held
LJ and/or Address
— Hold_
0 Date Point of
o 0 Transportation Shipment
fit? by Common Destination
0 Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
I Remains are Shipped, If Other than Above
2 Address
CC
Ui
Q-; Permission is hereby granted to dispose of the human re ains desc ibed above as i icated.
Date Issued 3- art3 Registrar of Vital Statistics
(signature)
District Number 6-(,2 Place _,, �, ,�,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition..-a9- 3 Place of Disposition Pi IN) t _- v t 4V1
W (address)
0)
c (section) (lot umber)/ (grave number)
o Name of Sexto or P so arge of Premises ( ca) 1 G
Z - AA�� //11,, (please print)
W Signatur //yam Title CCi��'► �'e >Al
-
(over)
DOH-1555 (02/2004)