Morse, Geraldine . .NEW YORK STATE DEPARTMENT OF HEALTH 11
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Geraldine R Morse Female
ilii Date of Death Age If Veteran of U.S. Armed Forces,
01/01/2017 78 years War or Dates
Place of Death Hospital, Institution or
litZ City, TX(gxxX Xxqg( Glens Falls Street Address Glens Falls Hospital
Manner of Death LArn Natural Cause 1=1Accident El Homicide 1=1Suicide ElUndetermined El Pending
Circumstances Investigation
42
ILI Medical Certifier Name Title
12 Eric Pillemer M D
iimi Address
100 Park Street Glens Falls, Ny 12801
ft
giiiii Death Certificate Filed District Number Register Number
City, TItYrklfr Y►iWXK Glens Falls 5601 2
['Burial Date Cemetery or Crematory
01/03/2017 Pine View Cemetery
Ai ['Entombment Address
iiiiiiii['Cremation Queensbury, NY 12804
Date Place Removed
N❑Removal and/or Held
and/or Address
I= Hold
Date Point of
Et) Transportation Shipment
C by Common Destination
ffi Carrier
Disinterment Date Cemetery Address
M ElReinterment Date Cemetery Address
Permit Issued to Registration Number
iN Name of Funeral Home Wilcox& Regan Funeral Home 01821
Eli Address
11 Alqonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
Z.
to
Permission is hereby granted to dispose of the human emains d cribed a ove as in:icate-,.
iin 0,---('
Date Issued 01/03/2017 Registrar of Vital Statistics f/ 77 ���__��
u`���j'/ (signature • .
giiii District Number 5601 Place Glens Falls
;_.::: I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
ill Date of Disposition (/J,//7 Place of Disposition a(4,,� (;
Fa
(address)
iti
ta
CC (section) jl(lot number) (\",,' (grave number)
• Name of Sexton or Person in Charge of Premises 64fis 3
9" 141Arir
I se print)
W.
Signature Title CRE YAWL
(over)
DOH-1555 (02/2004)