Wittman, Mary NEW YORK STATE DEPARTMENT OF HEALTH # At Vital Records Section BUrlaI _ Transit Permit
, Name First Middle Last Sex
Female<; Mary C \Wittman
tg Date of Death i Age If Veteran of U.S. Armed Forces,
,. 12/4/2011 1 8 l No
, War or Dates
Place of Death Hospital, Institution or
City. 1 X �( Glens Falls Street Address Glens Falls Hospital
Manner of Death(�Natural Cause Q Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
- Medical Certifier Name Title
S�z�A, PoutA_,-6 � k>
d ress V
y J LU Ct.� 1 N r
>:,>i' Death Certificate Filed Distrct Number F Register Num er
%5br City. iri Glens Falls 5601 -o2Y
Date E Cemetery or Crematory
0 Burial 12/6/2011 M Pine view Crematory
Address
Cremation Queensbury,NY
Date 1 Place Removed
.0 Q Removal and/or Held
1r= and/or Address
a_ Hold
a Date Point of
to Q Transportation ; Shipment
a by Common Destination
Carrier I
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
{��gi Permit Issued to Name of Funeral Home i Registration Number
yi.4.i:
���� Brewer Funeral home, Inc. � 00211
`' Address
' 24 Church St, Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
V`r.!! Remains are Shipped, If Other than Above
Address
Datef.M
Issued
Permission is hereby granted to dispose of the human remains described above a indi
:n. ,tom - �
���� %�G�ZDI Registrar of Vital Statistics
-` (signature)
KM District Number 5- `_ Place 6/(4S ICQWS /- 7 42k/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Place of Disposition
2 (address)
V)
(section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises
g (please print)
# Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61