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Anslow, Jerrilynn NEW YORK STATE DEPARTMENT OF HEALTH 41 —i-ll Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jerrilynn Jane Anslow Female Date of Death 1 2/2 6/2 01 3 Age 71 If Veteran of U.S. Armed Forces, War or Dates Place of Death Kingsbury Hospital, Institution or eity Towner-Village Street Address 135 Broad Street W Manner of Death Undetermined Pending Q Natural Cause �Accident �Homicide �Suicide � � Circumstances Investigation la Medical Certifier Name Title 41. John Stoutenburg MD Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 71�0 d. a Q OBurial Date Cemetery or Crematory 12/.27/2013 ['Entombment View Crematory Address ®Cremation 21 Quaker Road Queensbury, NY 12804 Date Place Removed Z Removal and/or Held 2 and/or Address i—+ Hold U) 0 Date Point of itti❑Transportation Shipment Q by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Edward L. Kelly Funeral Home 00519 Address 1019 US Route 9 Schroon Lake, NY 12870 Name of Funeral Firm Making Disposition or to Whom I Remains are Shipped, If Other than Above 2 Address LAI Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued I a- a 7 - 6 13 Registrar of Vital Statistics cc `o (c� (signature) District Number 576 ;„'Z. Place ! ©cam ,, �lou � I I certify that the remains of the decedent identified ab a were disposed of in accordance with this permit on: ILI Date of Disposition la_a-)-l3 Place of Disposition RiSt.i (,N-eior� 2 (address) Ili U, CC (section) (lot numb ) (grave number) 0 l3 Name of Sexton or Person in Charge of Premises r�r - "&fit Z (please print) in Signature 41 -AlTitle 1�Oi(. (over) DOH-1555 (02/2004)