Higgins, Jacqueline Ann fps \
Z
NEWYORKSTATEDEPARTMENTOFHEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jacqueline Ann Higgins Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/04/2022 79 Years War or Dates
f.. Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death KI Natural Cause illAccident EI Homicide Suicide Undetermined ❑Pending
W
I—I
U Circumstances Investigation
G Medical Certifier Name Title
Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 83
Burial Date Cemetery,Crematory or Facility Name
11/09/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
DDonation
0❑Removal Date Place Removed
and/or and/or Held
- Hold Address
N
0
0. Date Point of
(/) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
OReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 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
Remains are Shipped,If Other than Above
Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/07/2022 Registrar of Vital Statistics Aimee£ Mahoney(E(ectronicalty Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Oho I 2z Place of Disposition
2 (address)
W
N
CC (section) I) (lot number) c (grave number)
el• Name of Sexton or Person in Charge of Prem'ses P.$
Z (pi se print)
W Signature Title �' Tor(
DOH-1555(07/18)p 1 of 2
1 0 1
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#