Wilson, Dorothea •
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
,:: Name First Middle Last Sex
Dorothea V. Wilson Female
,.:•-::. Date of Death Age If Veteran of U.S. Armed Forces,
Dec . 7 , 1987 .: 7 1 yr s . War or Dates NO
. . ..... .. ... ...... ........... . . ..
z Place of Death Hospital, Institution or
.1,,u City,Town or Village Glens Falls , NY Street Address Glens Falls Hospital
.... . . . ........ ...................... . ._... ............ ..... ... . . . . ._'
0 Cause of beitii.
U4 Cardiac Failure, ASHD-CHF, Giant Cell Lymphoma
tu Medical Certifier Name Title
1:11: Harold J. Luria MD
ia Address
Mi 25 May St. , Glens Falls, NY 12801
Death Certificate Filed i. District Number Register Number
] i,, City,Town or Village Glens Falls, NY •. 5601 ‘,5-7
Date
• Cemetery or Crematory
Muria! :' Dec. 10, 1987 Pineview Cemetery
0 Cremation .-
Aoaress
. . . . .1.. Queensbury,ie New York 12801
Date
... . . . .......... . . . ...... .... .. .. . . . ..
z . Place Removed
0 0 Removal and/or Held
-.
1- and/or Hold i- Addiess-... . . ...... . . .................... ......... ....... . ... .. ... . . . ....... . .. ..
Cl,
a. . bate .i Point of
(n Ei Transportation by!
..- Carrier Shipment
a Common :. Destination
Date ':' Cemetery Address
. El Disinterment
................. . .. ..... . ... ................ .. . ...... . ..... .. .... ... . . .
Date i: Cemetery Address
-,:. 17 Reinterment
1.."1 . .••
Permit Issued to Registration Number
Name of Funeral Firm James F. Singleton, Inc. 02285
Address
1
314 Bay Rd. - P 0 Box 681, Glens Falls, NY 1280..... . .. . .. .
Name of unera Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
344::
;ti. ..
Permission is hereby granted to dispose of the dead aRri re Ins de ribed above as indicated.
Date Issued 12-9-87 Registrar of Vital Statistics irti-ZolAll'' -
ignature)
w,.:.
District Number
5601 Place City of Glens Falls, New York .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
Zuj Date of Disposition/? -t 0,.27 Place of Disposition p, „).e iii (-1,..) Q-Eb tY1 C.•T-c 2
(address) it")
-)
11J
u)
CC (section) (lot number) (grave number)
0 ta?
0 Name of S n Person in Charge of Premises t-\.c; C/ ,,,r e/ C-r. V71 o .--,heir
z
w 1?e,-va,,i,,_(Please Print) ..,
Signature fre,,,, oy___,d, Title 5\,pr.
DOH- 1555(9/86)p 1 of 2(formerly VS-61)