Wilhelm, Marion _, 5/C
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
n, Name First Middle Last Sex
kfl Marion Cora Wilhelm Female
" Date of Death Age If Veteran of U.S. Armed Forces,
6/24/2018 79 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls,NY Street Address 10 Keenan Street
Manner of Death ❑X Natural Cause n Accident 0 Homicide [Suicide ❑Undetermined �Pending
Circumstances Investigation
` Medical Certifier Name Title
Charles Yun,MD
0 Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
El Burial Date Cemetery or Crematory
El Entombment June 26,2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
'4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma remains descri ed above picated.
� .Date Issued _�(ah/� �)/K Registrar of Vital Statistics /` L��� -f'
I (signature)
4,4 District Number ���� Place
,. ,T2'1c
t` I certify that the remains of the decedent identified above w re disposed of in accord nce with this permit on:
Z Disposition � Place of Disposition ;— , ( -c_� Date of Z� t�_ p
lJJ (address)
Cl)
(section) /(I number (grave number)
aName of Sexton or Person in Charge of Premises itn 3�•it to
'Z ( ase print)
Signature GY( Title ri?eh1P►Tb�
(over)
DOH-1555(02/2004)