Loading...
Jackowski, Mary Ellen it 3.70 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Ellen Jackowski Female Date of Death Age If Veteran of U.S.Armed Forces, 04/22/2021 78 Years War or Dates �,. Place of Death Hospital,Institution or Z City,Town or Village Chester Town Warren Street Address 20 Stage Coach Road,Chester Town Warren,New York 12817 pManner of Death © Natural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined Pending W Circumstances Investigation WMedical Certifier Name Title 0 Mary Stein NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Villaje Chestertown 5652 5 ❑Burial Date Cemetery, " atory or Facility Name 04/27/2021 Pine Viev ematory 0 Entombment Address O Cremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed and/or and/or Held Hold Address 0 4. Date Point of Cl) ❑Transportation Shipment Q by Common Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander Baker Funeral Home 00037 Address 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/26/2021 Registrar of Vital Statistics Mindy Conway(E(ectronicalfy Signed) (signature) District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition ''� �21 I Zf Place of Disposition (address) W CC (section) (lot number) (grave number) 0 0 / L � Name of Sexton or Person in Charge of Premises Z (pleAse print) /� W Signature /.. Title ` M'yp( DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 0 1. r .7 3 8 Receipt Human remains of I delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#