Winchell, Louise NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
sir; Name First Middle Last I Sex
Louise M.Winchell 1 Female
.ti Date of Death 1—Age If Veteran of U.S. Armed Forces,
rP 12/28/2017 87 Years War or Dates
Place of Death Hospital, Institution or I
City, Town or Village Queensbury Town Street Address Westmount Health Facility
Manner of Death K) Natural Cause Accident Homicide ' ;Suicide [ Undetermined 1 Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
Of42 Gurney Ln,Queensbury Town,New York 12804
} `I Death Certificate Filed 11 District Number Register Number
City, Town or Village Queensbury 5657 166
''Burial Date I Cemetery or Crematory
lit U Entombment f Address j PineView Crematorium
&, N Cremation I Queensbury Town, New York
Date Place Removed
Removal and/or Held
No*'-'and/or Address
Hold 1 —
,40 Date Point of
Transportation Shipment
by Common Thestination
i Carrier
Disinterment
Date Cemetery Address
Dat--
e Cemetery Address
4Reinterment
Permit Issued to 1 Registration Number
.,-,-
to. Name of Funeral Home Mason Funeral Home 1 01117
Address
18 George St Po Box 277,Fort Ann, New York 12827-0277
4 Name of Funeral Firm Making Disposition or to Whom
— —I
4 Remains are__Shipped, If Other than Above
f Address
b
,x Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/29/2017 Registrar of Vital Statistics CarolneJBarber ECectrcmicalrySigned-
- (signature)
t`k District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ir Date of Disposition i'Z/2�//� Place of Disposition ?,Yl iJ_L-e,,,,, �r-enA,,.4if-1 _
1 / / (address)
4
(section) (lot numb") (grave number)
Name of Sexton or Per n,xn C rge of Premises J:_` << .n r4�t 4.1,
�, _ (please print)
w Signature U" _-_ Title L' ,--0 rna,1V/
J
/� (over)
DOH-1555 (02/2004)