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Gilligan, Jacqueline '•,_' Vt. c NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jacqueline Gilligan Female Date of Death Age If Veteran of U.S.Armed Forces, 01/01/2024 90 Years War or Dates F— Place of Death Hospital,Institution or Z City,Town or Village Argyle Town Street Address 179 Dutchtown Rd,Argyle Town,New York 12809 UU W Manner of Death ❑^ Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title CI Rita All NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Argyle District Number Register Number City,Town or Village 5750 1 Burial Date Cemetery,Crematory or Facility Name 01/03/2024 Pine View Crematory Entombment _ Address ©Cremation Queensbury,New York Donation 0 Removal Date Place Removed p and/or and/or Held Hold Address U) Transportation Date Point of s by Common Shipment Carrier Destination o Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above 2 Address Q W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/03/2024 Registrar of Vital Statistics Shelley Mckernon(Efectronica(tySigned) (signature) District Number 5750 Place Town Of Argyle I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I I S 12'1 Place of Disposition - ' rJ L .J (rAFJOT Q tL—, 2 (address) W Cl)CIC (section) A (lot number/, (grave number) 0 Name of Sexton or Person in Charge of Premises "' �.. ZZI p/ease prmtT W Signature Title 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#