Jackson, Ramona • 5g 2
NEW YORKSTATE DEPARTMENT OF HEALTH r Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ramona Jackson Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/21/2022 82 Years War or Dates
ZPlace of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death ❑X Natural Cause Accident El Homicide Suicide Undetermined ❑Pending
U Circumstances Investigation
a Medical Certifier Name Title
Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 110
Burial Date Cemetery,Crematory or Facility Name
07/22/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
g❑Removal Date Place Removed
and/or and/or Held
t— Hold Address
N
0
a Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
CC
uJ
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/22/2022 Registrar of Vital Statistics Caroline.7fi(degarde Barber(2°CectronicaulySigned)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II-
W Date of Disposition ?,23—% 2Z_ Place of Disposition j)/t/e 0e ) Cri i.4,f�
2 (address)
MI
CC N (section) �f / (lot number) (grave number)
^�7 ` t
Name of Sexton or Person in Char of Premises /1�/ r�.� F� ��
please print)
W Signature Title U ptr4 r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#