Haynes, Wilma i/Z
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
s
Name First Middle Last Sex
Wilma Mae Haynes Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 11, 2017 72 War or Dates
of Death Hospital, Institution or
LU own or Village Glens Falls Street Address Glens Falls Hospital
W anner of Death a Natural Cause ❑ Accident ❑ Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
Ui Medical Certifier Name Title
0 Dr. Darcy Gaiotti-Grubbs,
Address
100 Park Street, Pryne Pavillian, Glens Falls, NY 12801
D h Certificate Filed District Number Regist Number
Ci Town or Village �� � (i 5601 3o
❑Burial Date Cemetery or Crematory
January 13, 2017 Pine View Crematorium
'` ❑Entombment Address .
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0and/or Address
F Hold
Date Point of
ii 0 Transportation Shipment
01 by Common Destination
CI Carrier
m
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
..,,,,A Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W
�f-
' Permission is hereby granted to dispose of the human remains described above as indicate .
;E Date Issued l j t 3 j t Registrar of Vital Statistics \j\) Q , W
(signature)
3 District Number 5601 Place 6 S \\5 tV ,Y1
1--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition 01/13/2017 Place of Disposition Quaker Road Queensbury,NY 12804
2" (address)
(section) A/ (lot number) r, (grave number)
'0, Name of Sexton or Person in Charge of Pre ises (4 A't '
(Tease print)
LU` Signature l..a Title C 111 tit
(over)
DOH-1555 (02/2004)