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Wilkins, Sandra NEW YORK STATE DEPARTMENT OF HEALTH - W Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sandra Ruth Wilkins Female Date of Death Age If Veteran of U.S. Armed Forces, October 5, 2017 71 War or Dates rtPlace of Death Hospital, Institution or City, Town or Village Fort Edward Street Address 11 Williams Street Manner of Death Undetermined Pending XD Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑ Circumstances Investigation Medical Certifier Name Title Darci Ann Gaiotti-Grubbs, M.D Dr. ,._,A Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number q Register Number City, Town or Village Fort Edward w ❑Burial Date Cemetery or Crematory October 6, 2017 Pine View Crematory ,= Entombment Address i*©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ,❑ Removal and/or Held and/or Address Hold Date Point of _❑Transportation Shipment by Common Destination Carrier u ❑ Disinterment Date Cemetery Address fff❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom `_ Remains are Shipped, If Other than Above Address Permission is her by granted to dispose of the human re ai}n described above as indicated. Date Issued (' (D Registrar of Vital Statistics ff L (signature) District Numbers-7 Place k 'iiJic. ot6 L I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: iti►e.4),ZA•cJ 6!P r✓►.44 , t Date of Disposition 10/06/2017 Place of Disposition Qualer Road Queensbury,NY/12804 (address) 4.rt (section) (lot n mber) (grave number) a Name of Sexton or P • harge of Premises JtA. 1•Z' ba',nG' - (please print) Signature Title Pa 4//- (over) DOH-1555 (02/2004)