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Sullivan, Jackie NEW YORK STATE DEPARTMENT OF HEALTH 1 ti -lT (Z,3 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Jackie L. Sullivan Male 4" Date of Death Age If Veteran of U.S. Armed Forces, tFF February 29,2012 80 War or Dates Korean Place of Death Hospital, Institution or City, Town or Village Warrensburg Street Address 6 Warren Street . Manner of Death I Xi Natural Cause Accident I I Homicide Suicide Undetermined Pending `lg: Circumstances Investigation :g, Medical Certifier Name Title Paul Bachman Address HHIiT,Warrensburg,NY 12885 Death Certificate Filed District Number Register Number _°4a City, Town or Village Warrensburg 5660 ❑Burial Date Cemetery or Crematory Entombment March 1,2012 Pine View Crematory Address ©Cremation Quaker Rd., Queensbury,NY 12804 Date Place Removed Z Removal and/or Held O and/or Address E Hold N 0 Date Point of a. y Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 '''.1 Address .1 3809 Main Street,Warrensburg,NY 12885 :. Name of Funeral Firm Making Disposition or to Whom .1 Remains are Shipped, If Other than Above Address , ' 14. Permission is hereby granted to dispose of the human r escribed above as indicated. Date Issued 3/ /// Registrar of Vital Stati . s' /n-r4,_---4. 4 -- (signature) District Number 5660 Place Warrensburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition 11.4 (,,ion_ Place of Disposition f?.eUt& C a ,,�ri, , W (address) CO QCC (section) (lot number) (grave number) Name of Sexton or Person in Char e of Premises L�I+c IA Y �„.iEE' Z (please print) W Signature ____AIL Title Ctr/hK (over) DOH-1555 (02/2004)