Newcomb, Janice 3/1
(.171-F)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Janice Newcomb Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/07/2022 97 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 491 Dean Road,Kingsbury Town,New York 12839
p Manner of Death t l Natural Cause nAccident nHornicide Suicide nUndetennirted ❑Pending
UJ
1 I 1 'Circumstances Invesligatior'r
W Medical Certifier Name Idle
0 Michael Adams MD
Address
1299 Route 9,Gansevoort Hamlet,New York 12831
Death Certificate Filed.Town Of Kingsbury District Number Register Number
City,Town or Village 5762 6
ElBurial Date Cemetery,Crematory or Facility Name
04111/2022 Pine View Crematorium
DErdombment Address
nCremation oueensbury Town,New York
Donation
Date Place Removed
Removal
and/or and/or Held
Fs Hold Address
0
O. Date Point of
CD❑transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Dale Cemetery Address
El Reinter-merit
Permit Issued to Registration Number
Name of Funeral Horne Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,It Other than Above
5 Address
CC
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/11/2022 Registrar of Vital Statistics (,yr:tlius_,I24un&(E.ectrwria y,3'rr/rudl
(s aalur&)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed at in accordance with this permit on:
Z Date of Disposition 9 4111 Place of Disposition ?k.r
2 (address,'
W
NCr (setiiar/ (Io1 nu»iber! (grace aaruber/
Name of Sexton or Person in Charge of Premises L 4/ff
Z i (N(P eNr nl,'
W 0
Signature4/ Title
DOH-1555 To71i8)p i of 2
f15'PI 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of '°delivered on , 20
1
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#