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Jockimo, Bernice NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name irst Middle Last Sex '1 Female Bernice Anrj Jockimo # Date of Death Age If Veteran of U.S. Armed Forces, �x F' • 09/10/2018 82 Years War or Dates Place of Ceath Hospital, Institution or �- City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre Manner of Death©Natural Cause El Accident 0 Homicide []Suicide n Undetermined �Pending Circumstances Investigation ,�M Medical Certifier Name Title r . € Leonard Gelman MD Address Fi10421 State Route 40,Granville Town,New York 12832 Death Ce ificate Filed District Number Register Number • Ci , Tow or Villa•e Granville 5756 42 Date Cemetery or Crematory �BUrlal 09/11/2018 Pine View Crematory ❑Entombment Address i Crematign Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Q Transportation Shipment ` by Common Destination Carrier . Q Disinterment Date Cemetery Address El Reinterrrient Date Cemetery Address Permit Iss ed to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 ',4 Address 11 Lafayette t,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above -` Address r Permission is hereby granted to dispose of the human remains described above as indicated. fflo Date Issued 09/11/2018 Registrar of VitalStatistics jenny LindaWafter&e('ECectronica(CySigned) ii.,,,::, (signature) District Number 5756 Place Granville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1113 iig Place of Disposition 'JL Lrikty.-. • (address) =ryi (section) (lot nx nb,pr) (grave number) Name of Sexton or Person in Charge of Premises L ite �eMU'1 M (please p t) y Signature 4Title irffnli (over) DOH-1555 (02/2004)