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Jakway, Ethel E. .r 4il)3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Ethel E.Jakway Female Date of Death Age If Veteran of U.S.Armed Forces, 02/06/2022 80 Years War or Dates Place of Death Hospital,Institution or City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing 1,11 aManner of Death © Natural Cause Accident Homicide 0 Suicide Undetermined Pending Circumstances Investigation t i Medical Certifier Name Title fl Shardul Koppar DO Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 7 ❑Burial Date Cemetery,Crematory or Facility Name 02/07/2022 Pineview Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑ Donation Z❑Removal Date Place Removed and/or and/or Held F-• Hold Address a) LiTransportation Date Point of by Common Shipment Carrier Destination Disinterment Date Cemetery Address DReinterment Date Cemetery Address Permit Issued to Registration Number ' Name of Funeral Home Mason Funeral Home 01117 Address 18 George St Po Box 277,Fort Ann,New York 12827-0277 Name of Funeral Firm Making Disposition or to Whom 1.. Remains are Shipped,If Other than Above XAddress cc at to Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/07/2022 Registrar of Vital Statistics Richard Roberts(Electronically Signed) (signature) District Number 5725 Place Granville Village, 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 — —?-3- Place of Disposition f i" ei v,�,w C.iC M;for Y 2 (address) IIU- CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises rM t), C.tvirt S z (please print) Signature Title ()f./rude( DOH-1555(07/ p 1 of 2 1 h1 Public Health Law Sec. 4145(2b) Receipt -1 4 1 14‘i Human remains of ' / delivered on ' , 20 • -- Pine View Cemetery Representing the funeral home named on burial-pet-nit Official Funeral Directors Reg.or License#