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Jackson, Claudis Ann # IZ1 NEW YORKSTATE DEPARTMENT OF HEALTH ti Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Claudia Ann Jackson Female Date of Death Age If Veteran of U.S.Armed Forces, 12/01/2020 85 Years War or Dates i_ Place of Death Hospital,Institution or City,Town or Village Queensbury Town Street Address 16 Kenwood Circle,Queensbury Town, New York 12804 W Manner of Death Undetermined Pending G © Natural Cause Accident Homicide Suicide W U Circumstances Investigation W Medical Certifier Name Title Q Suzanne Bergin DO Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 214 ❑Burial Date Cemetery,Crematory or Facility Name 12/02/2020 Pine View Crematory 0 Entombment Address 1 Cremation Queensbury Town,New York 0 Donation Z Removal Date Place Removed p and/or and/or Held H Hold Address N 0 0. Date Point of U) ❑Transportation Shipment by Common Carrier Destination Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F.. Remains are Shipped,If Other than Above aAddress Or a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/02/2020 Registrar of Vital Statistics Caroline Wirdegarde Barber(Electronically Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: .,?..,1 Date of Disposition 1214 I TO Place of Disposition ZA-0"--- ILI (address) IW Cl) (section) (lot number) (grave number) O Name of Sexton or Person in Charge remises G "fit mval (p ase print) z W Signature ��� Title ril DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) - 4 2 5 4 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#