Spaulding, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
in Name First Middle Last Sex
Helen ID. 0
_ S ald, ng Female
>: Date of Death Age If Veteran of U.B. Armed Forces, '
iiiiiiiiL Aug. 18, 2018 81 yrs_ War or Dates n/a
iii Place of Death Hospital, Institution or
City, Town or Village Fort Ann Street Address 19 Needhamvi l le Lane
Manner of Death x❑Natural Cause ❑Accident 0 Homicide 0 Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
nii Medical Certifier Name Title
a David Foote, MD.
Address
340A Main St. , Hudson Falls, NY. 12839
Death Certificate Filed District Number Register Number
s«; City, Town or Village Fort Ann 5754 9
Date Cemetery or Crematory
❑Burial Aug. 20, 2018 PineView Crematorium
Address
>: ❑x Cremation Queensbury, NY. 12804
Date Place Removed
fl❑Removal and/or Held
and/or Address
Hold
6 Date Point of
y❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
' Name of Funeral Home Mason Funeral Home 01117
Nii Address
18 George St. , PO. Box 277, Fort Ann, NY. 12827
LI Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ns described abov indl)ated, /„__
€' Date Issued 0 8/2 0/18 Registrar of Vital Statistics 2`24(2/ _._ 1-2 tA-
sign ure)
i District Number 5754 Place 4).(_,),L__. / . `'S-2 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
5 Date of Disposition r e2-f`I 7 Place of Disposition ,ne, V;.�,� Cr ,cet0�`y
'm ( ddress)
LU
U)
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ,jcl riled)( S?))i c,./S
g (please print)
Signature Title Ci ram-c
(over)
DOH-1555 (9/98)