Wood, Mary NEW YORK STATE DEPARTMENT OF HEALTH �� 3Z
Vital Records Section Burial - Transit Permit
r
Name First Middle Last Sex
Mary Elizabeth Wood Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 25, 2017 56 War or Dates
Place of Death Hospital, Institution or
ui City, Town or Village Glens Falls Street Address Glens Falls Hospital
13 Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
a Frances Bollinger MD,
Address
161 Carey Rd Queensbu , NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village 5601 237
❑Burial Date Cemetery or Crematory
April 27, 2017 Pine View Crematorium
❑Entombment
Address
, ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
r❑ Removal and/or Held
0 and/or Address
`" Hold
0° Date Point of
Ci
❑Transportation Shipment
by Common Destination
II Carrier
41 ❑ Disinterment
Date Cemetery Address
,6, Date Cemetery Address
❑ Reinterment
iff
1 Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
:-f Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
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 human re ains de ribed ab ve as in cate .
Date Issued / Registrar of Vital Statistics ,(po��. 4/—C
(signature)
� District Number 5601 Place � lz �%
I certify that the remains of the decedent identified above were disposed of in accor ance with this permit on:
a, Date of Disposition 04/27/2017 Place of Disposition Quaker Road Queensbury,NY 12804
-2" (address)
W'
(section) ,,(lot number) (grave number)
Name of Sexton or Person in Charge of Premises
L tuft' . (tN�►1)
/� (pieaaa!llssse print)
w' Signature Zf Title (PE
(over)
DOH-1555 (02/2004)