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Jabaut, Fabiola NEW YORK STATE DEPARTMENT OF HEALTH B Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Fabiola Jabaut Female Date of Death Age If Veteran of U.S.Armed Forces, 12/09/2023 103 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 7 Lynnfield Drive,Queensbury Town, New York 12804 `p Manner of Death ❑X Natural Cause Accident E=IHomicide Suicide Undetermined Pending ✓ Circumstances Investigation WC1 Medical Certifier Name Title Thomas Coppens MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 187 Burial Date Cemetery,Crematory or Facility Name 12/12/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York []Donation 4❑Removal Date Place Removed and/or and/or Held Hold Address 0 O. Date Point of N Transportation IS by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F- Remains are Shipped,If Other than Above Address CC Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/11/2023 Registrar of Vital Statistics Caroline xl&egaree Barber(Electronically Signed) (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: Date of Disposition /Z-/Z-Z3 Place of Disposition a0 e e_.J .( 2 /address./ W CO CC (section) (l number/ (grave number) SName of Sexton or Person in Cha of P m' s '+ giOri z / / Title p (please print) W f1l� T�tt Signature �-P ec DOH-1555(07/18)p 1 of 2 r •• 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#