Wilson, Fred NEW YORK STATE DEPARTMENT OF HEALTH * ' it (g7
Vital Records Section Burial - Transit Permit
<::'_; Name First Middle Last Sex
il Fred A. Wilson Male
iiiiii Date of Death Age If Veteran of U.S. Armed Forces, __ _
',`` 0 3/0 8/2 016 63 War or Dates
RI Place of Death Hospital, Institution or
Z City, Town or Village Town of Hadley Street Address 490 Antone Mtn Road
VIManner of Death 0 Natural Cause Accident 0 Homicide 0 Suicide FlUndetermined ri Pending
INitj Circumstances Investigation
Medical Certifier Name Title
"a
Michael Sikirica MD
%: Address
50 Broad St . , Waterford, NY 12188
ia
''i Death Certificate Filed District Number Register Number
IN City, Town or Village Town of Hadley 4558
Date Cemetery or Crematory
❑Burial 03/13/2016 Pineview Crematory •
Address
: : ElCremation Queensbury, NY
Date Place Removed
0❑Removal and/or Held
rt and/or Address
Hold
0 Date Point of
[l Transportation Shipment
a' by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
til Permit Issued to Registration Number
"' Name of Funeral Home Densmore Funeral Home, Inc. 0Q448
W! Address
'al 7 Sherman Ave, Corinth, NY 12822
M.
Ni Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
21
at Permission is hereby granted to dispose of the human re ins described above as indi ed.
03/13/201 c
<F Date Issued 6Registrar of Vital Statistics Q( ..S.
Kt
a (signature)
i
4 District Number 4558 Place Hadley, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 3)1 N/l0 Place of Disposition_ ���.,,� ,,,,.
(address)
LfU
N
9 (section) / '(lot number) . (grave number)
g Name of Sexton or Person in Char e f Premises `� s` c
z IC Q° (please print) 1
Lilo Signature G.- .4L Title I1
g
(over)
DOH-1555 (9/98)