Burlett, Winifred 4 *r
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Winifred Burlett Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 29, 2013 87 War or Dates
k Place of Death Hospital, institution or
Z City, Town or Village Glens Falls Street Address Eden Park Health Care Center
tp Manner of Death N Natural Cause 0 Accident 0 Homicide 0 Suicide n Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Gwendolyn Morris-Dickinson
Address
,Fort Edward,NY 12828
Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls 5601 5Vcs'
®Burial Date Cemetery or Crematory
Entombment November 2, 2013 Pine View Cemetery
Address
❑Cremation , Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
• and/or Address
E Hold
N
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
f- Remains are Shipped, If Other than Above
2 Address
C
to
a. Permission is hereby granted to dispose of the human remainls descrbed abo indicated.
Date Issued _-/0/2U/20/S Registrar of Vital Statistics- - A .71-
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �l
W Date of Disposition // 2 2_0/3 Place of Disposition 1�, I/ 1 i' ) Celve- -&
2 // (address)
CO 011)-- LA__... a D! I
(sec ion) (lot number) (grave number)
Q Name of S on or Person in Charge of Premises ,'t t_ L. G�
Z (please print)
W 1 - ��Signatu t Titl ' , t. ._ ' '
‘_ (over)
DOH-1555(02/2004)