Wilson, Wendell • N!YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wendell Rowe Wilson Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 20, 2014 91 War or Dates WWII
1,,.. Place of Death Hospital, Institution or
pCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ' Natural Cause Accident 0 Homicide Suicide u Undetermined n Pending
#tl Circumstances Investigation
'j Medical Certifier Name Title
O Suzanne M.Rayeski DO
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Registeuuber
City, Town or Village Glens Falls,NY 5601
®Burial Date Cemetery or Crematory
November 24, 2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
n 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 Road,Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I-. Remains are Shipped, If Other than Above
Address
W
41.
Permission is hereb granted to dispose of the human emains d cribed ab ve as indi«=ted.
Date Issued Registrar of Vital Statistics Al
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified abovee er disposed of in accordance with this permit on:
Z Place of Disposition //ru / 2/ j� Date of Disposition )/ Z�f I 15( p Cif v;�?�y � Uta�i .�/
{ c / (address)
tY (sect, n) (lot number) (grave number)
pName of S ton or Person in Charge of Premises COA/4)'E t
`Z ,, (Please print)
Signatur .' Title
(over)
DOH-1555(02/2004)