Wieboldt, Lori 4 t . it $0 II NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lori A. Wieboldt Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 4,2016 56 War or Dates
; Place of Death Hospital, Institution or
Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital
c Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
lit Medical Certifier Name Title
Address
Death Certificate Filed District Number Registe,�Number
s' City, Town or Village Glens Falls 5601i(j r
❑Burial Date Cemetery or Crematory
December 6,2016 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
1 I Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
r Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
I
Permission is hereb4df
granted to dispose of the hum remains described- bove assjindicat
x
Date Issued I D �( Registrar of Vital Statistics � � /
�- (signature)
District Number Place f ( _J
1
I certify that the remains of the decedent identified above ere disposed of in accordance wit this permit on:
Z +,
W Date of Disposition 1115//k, Place of Disposition ?piOv.) 6/%4°rw-
W (address)
Cl)
pre (section) I/ (lot number) (grave number)
Name of Sexton or Person in Charge of Pr mises _ tint �tr 3e,in I it
Z (pl ase print)
W Signature a F Title C'REp#Re,
(over)
DOH-1555(02/2004)