Tucker, Jacqueline Faye NEW YORK STATE DEPARTMENT OF HEALTH zqa
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacqueline Faye Tucker Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2022 67 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
Manner of Death 1j Natural Cause Accident El Homicide Duicide Undetermined ❑Pending
V
W Circumstances Investigation
11JQ Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 190
Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
N Hold Address
O
d Date Point of
(/) Transportation
p by Common Shipment
Carrier Destination
111
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
CC
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/04/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition y I5 I't( Place of Disposition FL,A, /
W
2 (address)
W
CC
N (section) (lot n tuber/ (grave number)
Stt
0 Name of Sexton or Person in Cha of Premises 6a MNi
z (p4se print)
W Signature ( Title
DOH-1555(o7/18)p id 2
'ublic Health Law Sec. 4145(2b)
receipt
[uman remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#