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Wood, Jean NEW YORK STATE DEPARTMENT OF HEALTH -� Burial - Transit Permit Vital Records Section Name First Middle Last Sex Jean M. Wood Female Date of Death Age If Veteran of U.S. Armed Forces, June 7, 2011 89 War or Dates Place of Death Hospital, Institution or City, Town or Village Kingsbury Street Address 1112 Vaughn Road Manner of Death Natural Cause n Accident Homicide Suicide n Undetermined Pending Circumstances Investigation Medical Certifier Name Title James North, M.D Address 100 Broad St. Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village ,5'74,a 10 ❑Burial Date Cemetery or Crematory June 9, 2011 Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Removal Date Place Removed and/or and/or Held Hold Address Pine View Crematorium Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00276 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom s Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Registrar of Vital Statistics Date Issued ip/j ao%( (signature) District Number 71 � Place y ,su9L) I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition -tt�-t4 Place of Disposition ?laJ ew ( n.c}U (' ue__ (address) (section) / c (lot number) (grave number) Name of Sexton or P on in Charge f Premises ( ► (1411r --Ce..noott (phase print) C Signature Q i g Title Pf-ta-- (over) DOH-1555 (02/2004)