Wilkes, Grace L
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace A. Wilkes Female
Date of Death Age If Veteran of U.S. Armed Forces,
8/22/2018 79 War or Dates
• Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 51 Evergreen Lane
0 Manner of Death a Natural Cause ❑Accident ❑Homicide E Suicide ❑Undetermined I 1 Pending
Circumstances Investigation
w Medical Certifier Name Title
• Raji Sadal,MD
Address
2 Broad Street Plaza,Glens Falls,NY 12804
Death, ificatefi Filed District Number R gister Number
City, own r Village (o c t V
❑Burial Date Cemetery or Crematory
111
August 23, 2018 Pine View Crematory
Address
®Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
E Disinterment Date Cemetery Address
n 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
Remains are Shipped, If Other than Above
2 Address
te
IL Permission is hereby granted to dispose of the human re sins described a ove as\indicated.
1
Date Issued S 101-3l�1 1 Z_ Registrar of Vital Statistics
(signature) _
District NumberS-6 ) Place t Q t �1 Cam' s 0,r�I certify that the remains of the decedent identified above were disposed in accordanc with this permit on:
`�
Lu Date of Disposition- t1- I Place of Disposition P;etc, V tw Cr-
w (addressy
(section), (lot number) (grave number)
pName of Sexton or Person in Charge of Premises JefAm), S%t,arts
Z (please print)
W Signature Title C.fe,riclffrV
ac
(over)
DOH-1555(02/2004)