Wood, Marilyn NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
< Marilyn F. Wood Female
Date of Death Age If Veteran of U.S.Armed Forces,
1 0/7/1 1 84 War or Dates NO
} Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls Street Address Glens Falls ;Hospital
Manner of Death L Natural Cause Accident El Homicide Suicide 0 Undetermined Pending
itiCircumstances Investigation
LI
ul Medical Certifier Name Title
Evanglos Pallis MD
Address
100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Gies Falls 5601
]Burial Date Cemetery or Crematory
10/11 /11 Pine View Crematory
[]Entombment Address
I'.__ ®Cremation Queensbury, NY
Date Place Removed
Z ri❑Removal and/or Held
and/or Address
t= Hold
ilY
O Date Point of
IL Transportation to❑ p Shipment
ciby Common Destination
Carrier
Q Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiNi Name of Funeral Home M.B. Khmer Funeral Home 01 079
Address
82 Broadway, Fort Edward, NY 12828
ilq Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z. Address
..111
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 0/1 1 /1 1 Registrar of Vital Statistics S - A lt,,i
(signature)
District Number 5601 Place GlensF'alls, NY
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition 10 .((- :, ( Place of Disposition P;nR_.i, P (I.?yV ,Laos`t'v yin,
(address)
tti
I (section) (tot number) (grave number)
Name of Sexton or Person in Charge of Premises IArY cl tly gro,Idle
2 ] (please print)
Signature JiLi 31J Title Ct e►ic.'t ' , f
• (over)
DOH-1555 (02/2004)