Wagner, R NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
R. Elaine Wagner Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/06/2017 86 years War or Dates
.1 Place of Death Hospital, Institution or
CityIli , TgtC Glens Falls Street Address The Pines
Manner of Death ,Natural Cause 0 Accident 0 Homicide 0 Suicide �Undetermined �Pending
W. Circumstances Investigation
O.
Ili Medical Certifier Name Title
Gwendolyn Momi- Dickinson Physician Assistant
Address
170 Warren Street Glens Falls, Ny 12801
Mi Death Certificate Filed District Number Register Number
iiiiiiiiii City, TAW&MOM Glens Falls 5601 149
li
❑Burial Date Cemetery or Crematory
❑Entombment 03/08/2017 Pine View Crematory
in Address
lCremation Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
F= Hold
to
0 Date Point of
as Transportation Shipment
a by Common Destination
iiiiii Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
>" Address
11 Alqonkin Street Ticonderoga, N Y (Zg'3
ipi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
Ef
P` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/08/2017 Registrar of Vital Statistics C & -'-4S
(signature
District Number 5601 Place Glens Falls J N
mi$'' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
ILI Date of Disposition 3) 1 I1 Place of Disposition 'Pot 0lty (i or,,r
2 (address)
LU
U)
CC (section) ii(lot number) (grave number)
Name of Sexton or Person in Charge of Premises [ fs J i"^/�
z /l (pl ase print)
StO ignature l.� Title /13k p tIbiL
(over)
DOH-1555 (02/2004)