Wood, Maddison . -
milir
i 11 5Z
NEW YORK STATE DEPARTMENT OF HEALTH �
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex F
Maddison J. Wood
.ir Date of Death j Age If Veteran of U.S. Armed Forces,
µ{: 10/16/2011 i 0
War or Dates No
`'' Place of Death Hospital, Institution or
tri-
City. T, frOJe Glens Falls Street Address Glens Falls Hospital
,N Manner of Death(]Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
:i Doug Provost MD
Address
Glens Falls NY
Death Certificate Filed District Number Register Number
City,XICIO Sii Glens Falls 5601 h/
Date Cemetery of Crematory
❑Burial 10/18/2011 i Pine View Crematory
Address
Cremation Queensbury,NY
Date Place Removed
:El Removal and/or Held
and/or Address
Hold
• Date I Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date ' Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. ? 00211
Address
24 Church St., Lake Luzerne,NY 12846
1. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
s X Address
ta
Permission is hereb granted to dispose of the human remains d s ribed ove 'ndicated.
T. Date Issued /D��s LOU Registrar of Vital Statistics / � `Gam,
(signature)
: . District Number 5 2( Place O A-A, /Cy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
"" Date of Disposition 10i I Place of Disposition PI pt Ukew (_ 4oa ua-_
(address)
'-; (section) (I t numbs (grave number)
Name of Sexton or Perso -n Charge of emises t,tit r" s if
(please print)
Signature Title (►2e-f4 Azoe_
DOH-1555 (10/89) p. 1 of 2 VS-61