Judge, Meredith t it s Of
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
li Meredith Jenkins Judge Female
i .- Date of Death Age If Veteran of U.S. Armed Forces,
10/24/2018 80 War or Dates
` = Place of Death Hospital, Institution or
1
City, Town or Village Queensbury Street Address 30 Cedar Court
Manner of Death 0 Natural Cause E Accident 0 Homicide E Suicide 1-1 Undetermined n Pending
Circumstances Investigation
' Medical Certifi r Na Title
�C , Y1 ,c0w I rt1�
Address
• Death Certificate-riled d � District Number Register Number
Li City, Town or Village Queensbury,NY 5657 t
❑Burial Date Cemetery or Crematory
El Entombment October 25, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
F Hold
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O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
fl, Permit Issued to Registration Number
• Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
• Address
I 407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
X. Permission is hereby granted to dispose of the human remains described ab e s indicated.
,,vv -' ' �
Date Issued,�.Jl�-S 1ao.� Registrar of Vital Statistics J�-�1 ( ��
(signature)
District Numbe Place V 0 L,.--,...„ (2)-c- (------)\LA„s2_,c2_,,-Ne:..1")•
I certify that the remains of the decedent identified above were disposed of in accordanc;• with t is permit on:
Z
Ui Date of Disposition 10 Zb jig Place of Disposition f.�,.. a—.
(address)
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Cl)
CL
(section) (lot nujnber) (grave number)
pName of Sexton or Person in Charge of Premises �xr rtpk, J tM
Z it
(p!e se p►i►t)
Signature � Title /attAitt,2
(over)
DOH-1555(02/2004)