Wilson, Viola c
NEW YORK STATE DEPARTMENT OF HEALTH r y i
Vital Records Section Burial - 1 ransit Permit
Name First Middle Last Sex
Viola • H. Wilson • Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/1412016 87 War or Dates
#.- Place of Death Hospital, Institution or
Glens Falls Glens Falls Hospital
Z CO*Town or Village Street Address
ILI
Wa Manner of Death L Natural Cause 0 Accident ❑Homicide 0 Suicide Undetermined �Pending
Circumstances Investigation
uj Medical Certifier Name Title
Igbal Bashir Dr.
Address •
6 Hearts Way Queensbury, NY 12804
Death Certificate Filed District Number RegisterJyi ber
C Town or Village Glens Falls 1
'> ❑Burial Date Cemetery or Crematory
QEntombment 03/15/2016 • , Pine View Crematory
Address •
®Cremation 21 Quaker Rd. Queensbury, NY 12804
Date •Place Removed
Removal and/or Held
is❑and/or Address
H Hold
CO
0 Date Point of
cch❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
•
Permit Issued to Reggistration Number
Name of Funeral Home MB Kilmer Funeral Home 0T078
Address
136 Main St. So. Glens Falls, Ny 12803
Name of Funeral Firm Making Disposition or to Whom .
1 Remains are Shipped, If Other than Above
2 Address .
ILI
Permission is hereby ranted to dispose of the human remains des i ed ave icated.
Date Issued 03 /.T 20/6 Registrar of Vital Statistics
(signature)
District Number 6-670/ Place C7,P a, ,`/, N'f
1 I certify that the remains of the decedent identified above were disposed'of in accordance with this permit on:
Ul p I it Dispositionii t.Ais Creme Date of Disposition 3 f 1 b Place of t4,.1
2 (address)
in
ta
tt (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises �t� �L'l�'
z lease print)
3 Signature 2,,.
Title (1744114114
(over)
•
DOH-1555 (02/2004)