Woodard, Willam 0
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Roger Woodard Male
Date of Death Age If Veteran of U.S. Armed Forces,
�
,714 March 10, 2017 81 War or Dates
'y Place of Death Hospital, Institution or
u City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death nr1
144i Natural Cause 0Accident El Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Mark Quaresima,
Address
s 9 Carey Road Queensbury, NY 12804
• 5 Death Certificate Filed District Number O� Register Number 1 sco
City, Town or Village Glens Falls
❑Burial Date 2s> Cemetery or Crematory
March es, 2017 Pine View Crematory
❑Entombment Address
i ®Cremation Quaker Road Queensbury,NY 12804
441 Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
.-, Transportation Shipment
by Common Destination
Carrier
• Disinterment Date Cemetery Address
iliA❑
Reinterment Date Cemetery Address
a
2
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
t Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
3� .. Address
i
Permission is hereby granted to dispose of the human remains described above as indicated.
04
Date Issued 31 15 )i 7 Registrar of Vital Statistics W t.i,.)_.A„4. -
(signature)
• District Number Spa l Place 6 LQ..v- 5 R-.3 11 S N y
NAv
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-zo ,� jj
Date of Disposition 03/4§/2017 Place of Disposition Quaker Road Queensbury,NY 12804 J"ij'l-44,ic/ w b2/
(address)
(section) ( (lot/number)' (grave number)
`T . t Name of Sexton r n in Charge of Premises J�11G vi C� IyL�C��iz
(pleaseprint)
Signature ' Title 6.7e.- 4.
(over)
DOH-1555(02/2004)