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NEW YORK STATE DEPARTMENT OF HEALTH LF • - Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Irene Suzanne Jaffe Female
Date of Death Age If Veteran of U.S.Armed Forces,
05 20 2022 65 Years War or Dates
ZZ Place of Death Hospital,Institution or
City.Town or Village Chester Town Warren Street Address 1.31 Manna Road Chester Town Warren. New York 12817
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p Manner of Death 0 Natural Cause ❑Accident Homicide OSuicide ❑Undetermined FlPending
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0 Circumstances Investigation
LU Medical Certifier Name Title
Lynn Keil PA
Address
1340 State Route 9. Lake George Town. New York 12845
Death Certificate Filed Torn Of Chester District Number Register Number
City,Town or Village 5652 7
BurialEi
Date Cemetery,Crematory or Facility Name,v
05 2 1 2022 Pine',ie Crearonum
Entombment Address
Cremation Queenshury Town New York
DDonation
Z�Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
U)LJTransportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Ej Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-F,lcdermott Funeral Home Inc 00 14 I
Address
9 Pine St_Chestertown. New York I 28 17
Name of Funeral Firm Making Disposition or to Whom
t— Remains are Shipped.If Other than Above
2 Address
IX
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05 20 2022 Registrar of Vital Statistics
(signature)
District Number 5652 Place Town Of Chester
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F—
Z Date of Disposition ,5-Z/-.to2z.Place of Disposition NP (J t•.66t) cr-Uek
2 (address)
W
Q7-7) (section) (totnumber) (grave number)
0 Name of Sexton or Person in Charge o remise 1�A�Yl�I f9.ti� �(�
Z remise
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W Signature Title Qf�
DOH 1555(o//t8)p t of 2
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Public Health Law Sec. 4145(2b)
Receipt
1
Human remains of, ` 1 delivered on ' 20 - 3
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Pine View Cemetery ' Representing the funeral home named ov burin,pepnit
Official Funeral Directors Reg.or License#/ :-AtV "'�' e- _