Dickens, Winnifred t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
im Name First Middle Last Sex
WINNIFRED ANNE DICKENS Female
gii Date of Death Age If Veteran of U.S. Armed Forces,
iiiigi March 23,,2017 76 War or Dates n/i
}- Place of Death Hospital, Institution or
Z CityTown or Village Glens Falls„NY NY Street Address 21 Center Street Apt 1A
ILI '
O Manner of Death Natural Cause 0 Accident El Homicide Ei Suicide riUndetermined El Pending
lu Circumstances Investigation
uj Medical Certifier Name Title
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Address G4eX\-S S 1��`Y __) t-
Death Certificate Filed District Number Register Number
Mi City, Town or Village Glens Falls,,NY '5601 t g,S
❑Burial Date Cemetery or Crematory
❑Entombrnent April 3, 2017 Pine View Crematory
i;iiiiiiiiiiiAddress
;Cremation Queensbury,,NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
11) _.
0 Date Point of
Transportation Shipment
L3 by Common Destination
iiiiiiiii Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiigPermit Issued to Registration Number
iggi Name of Funeral Home Singleton Sullivan Potter 01596
iiiiig Address
407 Bay Road, Queensbury, NY 12804
Ili Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
ff<
L
` Permission is hereby granted to dispose of the human remains described a ove i dicated.
big Date Issued 3//24/ 017 Registrar of Vital Statistics - ti
(signature)
gig District Number 7 Place City of Glens Falls, ,NY
in I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
LU Date of Disposition ti i ti I(1 Place of Disposition file\)31-J �+h%etct�,,,.r
(address)
III
CA
a: (section) (lot number) (grave number)
/�`..�,j
{� Name of Sexton or Person in Charge of Premises �,���,. �►"�'t
Z ( ease prin
• Signature & --IT. Title tiZEPIO1
(over)
DOH-1555 (02/2004)