Deming, Wilhelmina w
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wilhelmina Beulah Deming Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 20, 2016 86 War or Dates n/a
I,., Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
pManner of Death 'X Natural Cause E Accident n Homicide n Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G William Cleaver,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601 2_
El Burial Date Cemetery or Crematory
ID Entombment January 22, 2016 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
�' Hold
N
0 Date Point of
NU Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
I-1 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
a Address
IZ
0. Permission is hereb granted to dispose of the human r mains described ab•ve as indi :ted.
Date Issued 011�t ;l(o Registrar of Vital Statistics ,.y
,i,--7(sign_ture) ���
District Number J70,0 j Place City of Glens Falls,NY 1 01
I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
Z
WW Date of Disposition 1 /2 2/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
Ili (address)
N Hudson 1 33C 2
ZIY (section) (lot number) (grave number)
Name of Sext., or Person in Charge of Premises Connie L. Goedert
(please print)
W Signature KJtt4. �; Title Cemetery Superintendent
(over)
DOH-1555(02/2004)