Weatherwax, Concetta ''''NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Concetta Marie Weatherwax Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 10,,2018 36 War or Dates
Place of Death Hospital,Institution or
wCity, Town or Village Queensbury Street Address 7 Grouse Circle
W Manner of Death[j Natural Cause ❑ Accident n Homicide D Suicide fl Undetermined 111 Pending
Circumstances Investigation
W Medical Certifier ! Name Title
William A.Tedesco, M.D. Dr.
Address
3 Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5t.D 5I (`13
®Burial Date' Cemetery or Crematory
December 17, 2018 Pine View Cemetery
Entombment Address
['Cremation Quaker Road Queensbury,NY 1280.4
Date Place Removed
z Removal and/or Held
d and/or Address
Hold
Date Point of
an Transportation Shipment
N by Common Destination
t3 Carrier
11 Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
M Address
CC
W
0_ Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (2••-1 a.- DO 1? Registrar of Vital Statistics
(signature)
District Number SV 5 I Place Oki e.c..n s b vrv�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 12/17/2018 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
LlJ Hudson #3 14-B 1
(section) pot number) (grave number)
O Name of `xton or Person ins �Chage of Premises Connie L. Goedert
W 1V (please print)
Signatu Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)