Wheeler, Eloise NEW YORK STATE DEPARTMENT OF HEALTH 2112
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eloise L. Wheeler FeMale
Date of Death Age If Veteran of U.S.Armed Forces,
}. April 2, 2017 91 War or Dates no
2 Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
w City,Town,or Village Street Address
0 Manner of Death E1 Natural Cause n Accident 111 Homicide El Suicide n Undetermined El Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Scott Biasetti MD
d Address
102 Park Street Glens Falls New York 12801
Death Certificate Filed District Numbe� on\ Register1i(u�b
; Town or Village ate f rtia r (,J,t} / q
n Burial Date G Cemetery or Crematory lJ
1 �� (� Pine View Crematory
❑Entombment Address
Town of Queensbury
®Cremation
Date Place Removed
0 El Removal and/or Held
- and/or Address
1' Hold
6 Date Point of
0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
c 0 Disinterment
El
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
F
Name of Funeral Firm Making Disposition or to Whom
X Remains are Shipped, If Other than Above
W Address
0.
Permission is her by anted to dispose of the human r ains d cribed a ve as indi ted.
Date Issued Registrar of Vital Statistics 0.60v.t7 `
(signat e)
District Number ® / Place „�
I certify that the remains of the decedent identified above were disposed of in accordance h this permit on:
Z
w Date of Disposition q/is-,p Place of Disposition 491K i i of .m.
2 (address)
tu
In
ft
section lot icumber(section) � ) (grave number)
O Name of Sexton or Person in Charge of Premises I fa `)4410
W /�/ (pl ase print)
Signature (/� Title r'OE/M)/t w_
(over)
DOH-1555 (02/2004)